Body Mass Index Is Associated With Myocutaneous Free Flap Reliability: Overcoming the Obesity Obstacle With a Proposed Clinical Algorithm to Identify and Manage High-Risk Patients Undergoing Gracilis Free Flap With Skin Paddle Harvest.

INTRODUCTION: The purpose of this study was to evaluate the role of body mass index (BMI) in predicting postoperative complications following myocutaneous free flap transfer. In addition, we sought to identify certain body composition variables that may be used to stratify patients into low- versus high-risk for gracilis myocutaneous free flap with skin paddle failure. METHODS: Using the National Surgical Quality Improvement Program database, we collected data for all patients who underwent myocutaneous free flap transfer from 2015 to 2021. Demographic data, medical history, surgical characteristics, and postoperative outcomes, including complications, reoperations, and readmissions, were collected. Body mass index was correlated with outcome measures to determine its role in predicting myocutaneous free flap reliability. Subsequently, we retrospectively obtained measurements of perigracilis anatomy in patients who underwent computed tomography angiography bilateral lower extremity scans with intravenous contrast at our institution. We compared body composition data with mathematical equations calculating the potential area along the skin of the thigh within which the gracilis perforator may be found. RESULTS: Across the United States, 1549 patients underwent myocutaneous free flap transfer over the 7-year study period. Being in obesity class III (BMI ≥40 kg/m2) was associated with a 4-times greater risk of flap complications necessitating a return to the operating room compared with being within the normal BMI range. In our computed tomography angiography analysis, average perigracilis adipose thickness was 18.3 ± 8.0 mm. Adipose thickness had a strong, positive exponential relationship with the area of skin within which the perforator may be found. CONCLUSIONS: In our study, higher BMI was associated with decreased myocutaneous free flap reliability. Specifically, inner thigh adipose thickness can be used to estimate the area along the skin within which the gracilis perforator may be found. This variable, along with BMI, can be used to identify patients who are considered high-risk for flap failure and who may benefit from additional postoperative monitoring, such as the use of a color flow Doppler probe and more frequent and prolonged skin paddle monitoring.

Tourniquet Use in Extremity-Based Microsurgery.

BACKGROUND: The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. The authors hypothesize that tourniquets enhance visualization, bloodless approaches to vessel harvest, flap elevation, and anastomosis without added complications. METHODS: A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between January 2018 and February 2022 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet use during three operative segments: (1) flap elevation, (2) vessel harvest, and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. RESULTS: A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was trauma (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). A total of 70, 61, and 32% of procedures used a tourniquet for flap elevation, vessel harvest, and for anastomosis, respectively. Statistical analyses identified no difference in complication rates for procedures for which a tourniquet was or was not used for interventions. CONCLUSION: Based on these results, the authors state that tourniquets can be utilized for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates.

Nerve Imaging in the Wrist.

Neuropathic symptoms involving the wrist are a common clinical presentation that can be due to a variety of causes. Imaging plays a key role in differentiating distal nerve lesions in the wrist from more proximal nerve abnormalities such as a cervical radiculopathy or brachial plexopathy. Imaging complements electrodiagnostic testing by helping define the specific lesion site and by providing anatomical information to guide surgical planning. This article reviews nerve anatomy, normal and abnormal findings on ultrasonography and magnetic resonance imaging, and common and uncommon causes of neuropathy.

The mental health of forcibly displaced couples.

Most current research investigating traumatic stress is focused on its effects at the individual level, utilizing the implicit assumption that trauma-related disorders are mutually independent within families and communities. However, there is reason to assume that trauma-related symptoms within couples are influenced by each partner's risk factors and symptoms. Using the actor-partner interdependence model, this study aimed to test whether symptoms of posttraumatic stress disorder (PTSD) and depression were predicted by participants' partner's exposure to traumatic events over and above the influence of the participant's own experiences. For this purpose, we interviewed 687 heterosexual, married Iraqi and Syrian couples in Iraq's Kurdistan region who had been forcefully displaced. We assessed symptoms of PTSD and depression using locally validated scales. Nearly all participants (98.8%) reported exposure to at least one traumatic event, with husbands reporting exposure to a higher number of traumatic events than wives, d = 0.48, p < .001. More than half of the participants met the criteria for a probable PTSD (61.1%) or major depressive disorder diagnosis (60.4%). Within couples, significant actor effects of experienced trauma exposure on personal PTSD and depressive symptoms were observed for both husbands and wives. Further, there were significant partner effects of wives' traumatic experiences on husbands' PTSD and depressive symptoms as well as of husbands' traumatic experiences on wives' PTSD and depressive symptoms. The findings argue for the interdependence of trauma-related symptoms within dyads in a dual-trauma context, suggesting the presence of intracouple transmission of trauma-related symptoms.

Imaging Evaluation of Medial and Lateral Elbow Pain: Acute and Chronic Tendon Injuries of the Humeral Epicondyles.

Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.

Musculoskeletal Ultrasonography of the Extremities: Clinical and Ultrasonographic Correlation.

Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal injuries. It can be a useful imaging modality for clinical correlation of physical examination findings as well as an aid for image-guided procedures. Understanding the settings in which it is a helpful adjunct will have implications on efficiency and cost utility. The objectives of this chapter are to provide a background of ultrasonography as a musculoskeletal imaging modality, provide clinical correlation for ultrasonographic findings for common upper extremity pathology, review the diagnostic efficacy of ultrasonography for image-guided procedures, and provide insight into the cost utility of ultrasonography guidance for therapeutic injections.

Semi-Precise Analytical Method for Investigating the Liftoff Variation on the Hall Sensor in Metal Defect Sensing.

Hall-effect sensors are used to detect metal surface defects both experimentally and numerically. The gap between the specimen and the sensor, called the liftoff, is assumed to remain constant, while a slight misplacement of a sample may lead to incorrect measurements by the Hall-effect sensor. This paper proposes a numerical simulation method to mitigate the liftoff issue. Owing to the complexity of conducting precise finite-element analysis, rather than obtaining the induced current in the Hall sensor, only the magnetic flux leakage is obtained. Thus, to achieve a better approximation, a numerical method capable of obtaining the induced current density in the circumferential direction in terms of the inspection direction is also proposed. Signals of the conventional and proposed approximate numerical methods affected by the sensor liftoff variation were obtained and compared. For small liftoffs, both conventional and proposed numerical methods could identify notch defects, while as the liftoff increased, no defect could be identified using the conventional numerical method. Furthermore, experiments were performed using a variety of liftoff configurations. Based on the results, considering the threshold of the conventional numerical method, defects were detected for greater liftoffs, but misdetection did not occur.

Proximal Row Carpectomy Versus 4-Corner Fusion: Incidence, Conversion to Fusion, and Cost.

PURPOSE: The primary objective of this study was to compare incidence, demographic trends, and rates of subsequent fusion between proximal row carpectomy (PRC) and 4-corner fusion (4CF) among patients in the United States. METHODS: A total of 3,636 patients who underwent PRC and 5,047 who underwent 4CF were identified from the years 2005 through 2014 among enrollees in the PearlDiver database. Regional distribution, demographic characteristics, annual incidence, comorbidities, and subsequent wrist fusion were compared between the 2 groups. Of the patients identified, 3,512 from each group were age- and sex-matched and subsequently compared for rates of converted fusion, 30- and 90-day readmission rates, and average direct cost. RESULTS: Patients undergoing 4CF and PRC did not have statistically significant differences in comorbidities. The incidence of the procedures among all subscribers increased for both PRC (1.8 per 10,000 to 2.6 per 10,000) and 4CF (1.2 per 10,000 to 2.0 per 10,000) from 2005 to 2014. Comparing the matched cohorts, patients who underwent 4CF had a higher rate of subsequent fusion than those who underwent PRC (2.67% vs 1.79%). Readmission rates were not significantly different at 30 or 90 days. Average direct cost was significantly greater for 4CF than for PRC. CONCLUSIONS: Both PRC and 4CF have been utilized at increasing rates in the past decade. Wrist fusion rates and average costs are higher in the 4CF group without a significant difference in readmission rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Design and Optimization of an MFL Coil Sensor Apparatus Based on Numerical Survey.

In this study, we aimed to design a coil sensor prototype capable of detecting metallic area loss based on numerical simulations using the magnetic flux leakage (MFL) method. Unlike previous numerical simulation-based studies, which are only conducted to obtain the MFL itself, the main objectives of this study were (1) to acquire the induced current in the coil sensor and (2) to optimize the apparatus based on a time-dependent numerical analysis. As a result, the optimum values of parameters in magnetizing and sensing units were obtained numerically. A magnetic sensor prototype was then fabricated using the optimum parameters obtained by numerical parametric study. Finally, experimental validation tests were conducted on a solid steel rod specimen with a stepwise cross-sectional reduction flaw. It was observed that numerical simulation had approximately 91% precision compared to the experimental test. The results reveal that application of a realistic numerical simulation of an MFL coil sensor can probably provide essential information for MFL-sensor fabrication and allows for preventive measures to be taken before manufacturing failure or defect misdetection.

Trauma and perceived social rejection among Yazidi women and girls who survived enslavement and genocide.

BACKGROUND: In August 2014, the Islamic State of Iraq and Syria (ISIS), a terrorist organization, attacked the Yazidi's ancestral homeland in northwestern Iraq. Among other atrocities, they abducted thousands of women and girls and traded many of them into sexual slavery. The aim of this study is to determine the mental health of women and girl survivors of these events in relation to enslavement and experiences with genocide-related events, as well as perceived social rejection in their community. METHODS: Between February and July 2017, trained local assessors interviewed a sample of 416 Yazidi women and girls (65 of whom had survived sexual enslavement), aged between 17 and 75 years, and living in internally displaced person camps in the Kurdistan Region of Iraq. Post-traumatic stress disorder (PTSD) and depression symptoms were assessed using validated Kurdish versions of standard instruments. Scales for trauma exposure and perceived rejection were developed for the purpose of this study. RESULTS: Participants reported a high number of traumatic events. More than 80% of girls and women, and almost all participants who were formerly enslaved, met criteria for a probable DSM-5 PTSD diagnosis. Trauma exposure and enslavement predicted poor mental health. In addition, among formerly enslaved girls and women, perceived social rejection in their community mediated the relationship between traumatic enslavement events and depression symptoms. CONCLUSIONS: In a context of maximum adversity, enslavement and war-related events contribute to high levels of PTSD and depression. Perceived social rejection seems to play a role in the relationship between trauma exposure and mental health among abducted genocide survivors. Providing psychosocial support and treatment for Yazidi people is essential and urgently required.

The validity of Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) as screening instrument with Kurdish and Arab displaced populations living in the Kurdistan region of Iraq.

BACKGROUND: The Posttraumatic Stress Disorder Checklist (PCL) is a valid and reliable self-report measure for the assessment of Posttraumatic Stress Disorder (PTSD). Recently the PCL was updated according to the DSM-5 criteria for PTSD. So far only a few studies have examined the psychometric properties of the PCL-5, and all of these are restricted to populations living in industrialized countries. The aim of this study was to determine the psychometric properties and diagnostic utility of the PCL-5 as a screening instrument for war-affected displaced Kurdish and Arab populations. The specific goal was to determine a contextually valid cut-off score for a probable diagnosis of PTSD. METHODS: The PCL-5 was translated into Arabic and two Kurdish dialects. Trained interviewers administered these translations as assisted self-reports to 206 adults living in camps for displaced people in Iraq, together with depression and war-exposure instruments. Two weeks later, 98 randomly chosen subjects were reassessed by expert clinical psychologists. In the absence of a gold-standard instrument with proven validity in this context, the expert interviewers applied the PCL-5 items in the form of a clinical interview and used a DSM-5-algorithm to determine a diagnosis of PTSD. Receiver operator characteristics (ROC) were performed to determine a valid cutoff-score. RESULTS: The internal consistency of the PCL-5 was high (alpha = .85) and the instrument showed an adequate convergent validity. Using the cut-off score of 23, the PCL-5 achieved the optimal balance of sensitivity and specificity (area under the curve = .82, p < .001; sensitivity = .82, specificity = .70). CONCLUSIONS: Given that the comparison of the two assessments included both a re-test interval and validation by different interviewers, our results indicate that the PCL-5 can be recommended as an assessment and screening instrument for Kurdish and Arab populations.

FGF21 is not required for glucose homeostasis, ketosis or tumour suppression associated with ketogenic diets in mice.

AIMS/HYPOTHESIS: Ketogenic diets (KDs) have increasingly gained attention as effective means for weight loss and potential adjunctive treatment of cancer. The metabolic benefits of KDs are regularly ascribed to enhanced hepatic secretion of fibroblast growth factor 21 (FGF21) and its systemic effects on fatty-acid oxidation, energy expenditure (EE) and body weight. Ambiguous data from Fgf21-knockout animal strains and low FGF21 concentrations reported in humans with ketosis have nevertheless cast doubt regarding the endogenous function of FGF21. We here aimed to elucidate the causal role of FGF21 in mediating the therapeutic benefits of KDs on metabolism and cancer. METHODS: We established a dietary model of increased vs decreased FGF21 by feeding C57BL/6J mice with KDs, either depleted of protein or enriched with protein. We furthermore used wild-type and Fgf21-knockout mice that were subjected to the respective diets, and monitored energy and glucose homeostasis as well as tumour growth after transplantation of Lewis lung carcinoma cells. RESULTS: Hepatic and circulating, but not adipose tissue, FGF21 levels were profoundly increased by protein starvation, independent of the state of ketosis. We demonstrate that endogenous FGF21 is not essential for the maintenance of normoglycaemia upon protein and carbohydrate starvation and is therefore not needed for the effects of KDs on EE. Furthermore, the tumour-suppressing effects of KDs were independent of FGF21 and, rather, driven by concomitant protein and carbohydrate starvation. CONCLUSIONS/INTERPRETATION: Our data indicate that the multiple systemic effects of KD exposure in mice, previously ascribed to increased FGF21 secretion, are rather a consequence of protein malnutrition.

Soft tissue coverage for IIIB fractures: from timing to coverage options.

Open tibia fractures are the most common open long bone injury. Most of these injuries involve a high-energy mechanism. Many standards for management have been created to provide guidance and a baseline for quality. There are several factors that must be considered when determining the timing of coverage for an open fracture with soft tissue compromise. Understanding the available options for soft tissue coverage, including local/rotational flaps and free tissue transfer, will allow for a tailored approach based on the personality of the injury. The aim of this review was to characterize the critical window of treatment based on the current literature and to provide a review of the available soft tissue coverage options.

An Examination of Complication Rates and Surgery Durations in Elective Hand Surgery During the COVID-19 Pandemic.

Background: The COVID-19 pandemic presented unique challenges to hand surgeons as hospitals worked to adapt to unprecedented demands on resources and personnel. The purpose of this study is to evaluate the impact of COVID-19 on outcomes in elective hand surgery using a large national database. Methods: This is a retrospective review of the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) dataset for patients undergoing elective hand procedures in 2019 and 2020. Demographics, comorbidities, procedural factors, and outcomes were compared between cases occurring in 2019 and 2020. Multivariable regressions were performed to evaluate the association between operative year and 30-day outcomes. Results: A total of 8971 patients were included with a mean age of 52.2 ± 16.7 and 52.8 ± 16.4 years for the 2019 and 2020 cohorts, respectively. Compared to the 2019 cohort, the 2020 cohort demonstrated higher prevalence of obesity (43.3% vs 40.8%, P = 0.019), hypertension requiring medication (32.9% vs 35.0%; P = 0.046), and American Association of Anesthesiologists (ASA) class ≥ 3 (30.4% vs 27.0%; P < 0.001). There were no significant differences in outcomes including 30-day readmissions, reoperation, or complications between cohorts on unadjusted or multivariable analysis. Conclusions: Elective hand cases performed during the pandemic were associated with longer operating times and more frequently involved patients with greater comorbidities. Despite these differences, patients undergoing surgery during the pandemic demonstrated similar outcomes including complications, readmissions, and reoperations compared to those undergoing surgery the year prior, suggesting that even in the setting of a pandemic, performing elective surgery is safe without an increased risk to the patient.

A Comparison of Outcomes in Acute Perilunate Injuries: Systematic Review and Meta-Analysis of Treatment Approaches.

BACKGROUND: Perilunate dislocations (PLD) and fracture-dislocations (PLFD) comprise a spectrum of high-energy wrist injuries. The purpose of this review was to review operative strategies for perilunate injuries based on approach and compare outcomes. METHODS: A systematic review of literature on PLD and fracture-dislocations was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed and EMBASE databases were queried for literature. Inclusion criteria included English studies reporting clinical or functional outcomes of acute PLD and PLFD. RESULTS: Twenty-nine full-text articles (604 PLD and PLFD injuries) were included. The most common method of PLD and PLFD fixation is through an open approach with combined volar and dorsal exposure. There were no differences between approaches with regard to total arc range of motion, grip strength, Mayo Wrist Score, or mean scapholunate angle. Similarly, there was no difference between approaches and postoperative radiographic arthritis or complications. Most patients were able to return to their prior level of function and work. The incidence of postoperative complications ranged from 0% to 22.5%. CONCLUSION: Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. The most common method of PLD and PLFD fixation in the literature is through an open approach with combined volar and dorsal exposure. There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability. LEVEL OF EVIDENCE: I, Systematic Review.

Association of Timing With Postoperative Complications in the Management of Open Distal Radius Fractures.

BACKGROUND: This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. METHODS: Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. RESULTS: One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. CONCLUSION: Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. LEVEL OF EVIDENCE: Level IV.

Evaluation of a Fast Method to Measure High-Frequency Audiometry Based on Bayesian Learning.

This study aimed to assess the validity of a high-frequency audiometry tool based on Bayesian learning to provide a reliable, repeatable, automatic, and fast test to clinics. The study involved 85 people (138 ears) who had their high-frequency thresholds measured with three tests: standard audiometry (SA), alternative forced choice (AFC)-based algorithm, and Bayesian active (BA) learning-based algorithm. The results showed median differences within ±5 dB up to 10 kHz when comparing the BA with the other two tests, and median differences within ±10 dB at higher frequencies. The variability increased from lower to higher frequencies. The BA showed lower thresholds compared to the SA at the majority of the frequencies. The results of the different tests were consistent across groups (age, hearing loss, and tinnitus). The data for the BA showed high test-retest reliability (>90%). The time required for the BA was shorter than for the AFC (4 min vs. 13 min). The data suggest that the BA test for high-frequency audiometry could be a good candidate for clinical screening. It would add reliable and significant information without adding too much time to the visit.

The Variable Insertional Anatomy of the Abductor Pollicis Longus: Functional Relevance and Relationship to Adjacent Thumb Extensors.

BACKGROUND: The abductor pollicis longus (APL) is classically described as inserting on the base of the first metacarpal. This study analyzed APL insertional anatomy and quantified the size of various elements of the extensor side of the thumb to determine associations with size and function. METHODS: Twenty-four formalin-preserved upper limbs were dissected. The insertional anatomy of the APL, extensor pollicis brevis, and extensor pollicis longus were characterized, and the capacity of APL tendon slips to perform palmar abduction of the first digit was quantified based on slip size and insertion. RESULTS: The mean number of APL tendon slips observed was 2.3. Abductor pollicis longus insertion sites included the base of the first metacarpal, trapezium, abductor pollicis brevis, and opponens pollicis. Only 4 specimens had a solitary metacarpal slip, while 83% of specimens had insertions onto at least 1 thenar muscle. A total of 62.5% of APL tendons exhibited some form of branching that we categorized into "Y" and "Z" patterns. In assessing palmar abduction capacity, we found that APL tendon slips inserting into the base of the first metacarpal were larger in cross-sectional area than nonmetacarpal slips and reproduced complete palmar abduction of the digit in the absence of nonmetacarpal slips. The abduction capacity of APL tendon slips was not correlated to the cross-sectional area. CONCLUSIONS: There is significant variability in APL tendon slips, branching patterns, and insertional anatomy. These findings provide further understanding of the function of the APL and its surgical implications.

Reducing Tourniquet Pressures in Hand Surgery: Are Lower Pressures as Effective?

Background Pneumatic tourniquets are widely used in hand surgery. Elevated pressures can be associated with complications, and thus, guidelines based on patient-specific tourniquet pressures have been recommended. The primary aim of this study was to determine whether lower tourniquet values based on systolic blood pressure (SBP) could be effectively applied in upper extremity surgery. Methods A prospective case series of 107 consecutive patients undergoing upper extremity surgery with use of a pneumatic tourniquet was performed. Tourniquet pressure used was based on the patient's SBP. The tourniquet was inflated based on our predetermined guidelines: 60 mm Hg was added for SBP < 130 mm Hg, 80 mm Hg for SBP between 131 and 190 mm Hg, and 100 mm Hg for SBP > 191 mm Hg. The outcome measures included intraoperative tourniquet adjustment, surgeon-rated quality of bloodless operative field and complications. Results The mean tourniquet pressure was 183 ± 26 mm Hg with a mean tourniquet time of 34 minutes (range: 2-120 minutes). There were no instances of intraoperative tourniquet adjustment. The surgeon-rated quality of bloodless operative field was excellent in all patients. No complications were associated with the use of a tourniquet. Conclusion Tourniquet inflation pressure based on SBP is an effective method to provide a bloodless surgical field in upper extremity surgery at significantly lower inflation pressures than are the current standards.