Treatment of Pyogenic Flexor Tenosynovitis in the Emergency Department Setting With WALANT Technique.

BACKGROUND: The standard of care for treatment of pyogenic flexor tenosynovitis (PFT) involves antibiotic therapy and prompt irrigation of the flexor tendon sheath, traditionally performed in the operating room. With the acceptance of wide-awake local anesthesia no tourniquet (WALANT) hand surgery and its potential ability to minimize time to flexor tendon sheath irrigation, we sought to determine whether closed irrigation of the flexor tendon sheath could be safely and effectively performed in the emergency department setting with WALANT technique. METHODS: A retrospective review was conducted of the senior author's hand surgery consultations over a 12-month period. Six patients were identified who were diagnosed with PFT and subsequently underwent irrigation of the flexor tendon sheath using WALANT technique. Patient outcomes such as length of hospital stay, need for reoperation, infectious etiology, perioperative complications, and postprocedure range of motion (ROM) were identified. RESULTS: Six patients with diagnosis of PFT underwent irrigation of the flexor tendon sheath in the emergency department with local anesthesia only. The irrigation procedures were all well-tolerated. One patient required reoperation due to lack of appropriate clinical improvement following initial irrigation. Four of 6 patients regained their preinjury ROM while the remaining 2 patients had mild proximal interphalangeal joint extension lag. There were no complications associated with the procedures. CONCLUSIONS: Surgical treatment of PFT with closed irrigation of the flexor tendon sheath in the emergency department utilizing WALANT technique was safe, effective, and well-tolerated. Local anesthesia alone can be used effectively for irrigation procedures of the flexor tendon sheath.

Persistent Intracranial Hypertension in a Cranial Vault Remodeling Patient With Open Skull Fractures From Horse Kick.

A 4-year-old female with prior cranial vault remodeling for nonsyndromic bilateral coronal craniosynostosis sustained a severe traumatic brain injury with open skull fractures from a horse kick. Her post-traumatic course was complicated by persistently elevated intracranial pressure despite neurosurgical decompressions, maximum medical therapy, and trial of multiple pressure monitoring devices. She eventually had improvement in her intracranial pressures and made a full neurologic recovery. This case highlights the potential severity of horse kick injuries, the possible etiology of persistent intracranial hypertension in cranial vault remodeling patients following traumatic brain injury, the importance of a multi-team approach in the initial evaluation and postoperative follow-up of all craniosynostosis patients, and the necessity of helmet utilization.

Perceptions of Preparedness in Plastic Surgery Residency Training.

BACKGROUND: Graduating competent surgical residents requires progressive independence during training. Recent studies in other surgical subspecialties have demonstrated overall fewer opportunities for resident independence due to changes in residency regulations, medical-legal concerns, and financial incentives. A survey study was conducted to assess perceived autonomy and preparedness during plastic surgery residency training and to assess factors affecting autonomy. METHODS: Anonymous electronic surveys were sent to attending surgeons and residents of all Accreditation Council for Graduate Medical Education accredited programs during the 2017-2018 academic year. Seventy-two integrated and 42 independent plastic surgery programs were surveyed. Analysis of responses was performed using the Fisher exact and chi-square tests. RESULTS: There were 158 attending surgeon and 129 resident responses. The resident and attending surgeon response rates were 11.7% and 16.8%, respectively. Eighty-seven percent of residents felt their operative experience within residency prepared them for practice. Residents felt least prepared in aesthetics and pediatrics/craniofacial surgery. Attending surgeons perceived that they provided residents graduated autonomy throughout residency. Residents identified the complexity of a procedure, attending surgeon supervision, and time constraints as the largest factors influencing resident autonomy. Attending surgeons noted patient safety as the largest deterrent to autonomy. CONCLUSIONS: In our study, a majority of plastic surgery residents were found to feel prepared for practice after residency; however, preparedness gaps within training still exist in aesthetic and craniomaxillofacial surgery. Plastic surgery programs must work to develop training programs that simultaneously promote resident autonomy, while prioritizing patient safety, and maintaining productivity and financial well-being.

Assessing photoreceptor structure in patients with traumatic head injury.

OBJECTIVE: Previous work using adaptive optics scanning light ophthalmoscopy (AOSLO) imaging has shown photoreceptor disruption to be a common finding in head and ocular trauma patients. Here an expanded trauma population was examined using a novel imaging technique, split-detector AOSLO, to assess remnant cone structure in areas with significant disruption on confocal AOSLO imaging and to follow photoreceptor changes longitudinally. METHODS AND ANALYSIS: Eight eyes from seven subjects with head and/or ocular trauma underwent imaging with spectral domain optical coherence tomography, confocal AOSLO and split-detector AOSLO to assess foveal and parafoveal photoreceptor structure. RESULTS: Confocal AOSLO imaging revealed hyporeflective foveal regions in two of eight eyes. Split-detector imaging within the hyporeflective confocal areas showed both remnant and absent inner-segment structure. Both of these eyes were imaged longitudinally and showed variation of the photoreceptor mosaic over time. Four other eyes demonstrated subclinical regions of abnormal waveguiding photoreceptors on multimodal AOSLO imagery but were otherwise normal. Two eyes demonstrated normal foveal cone packing without disruption. CONCLUSION: Multimodal imaging can detect subtle photoreceptor abnormalities not necessarily detected by conventional clinical imaging. The addition of split-detector AOSLO revealed the variable condition of inner segments within confocal photoreceptor disruption, confirming the usefulness of dual-modality AOSLO imaging in assessing photoreceptor structure and integrity. Longitudinal imaging demonstrated the dynamic nature of the photoreceptor mosaic after trauma. Multimodal imaging with dual-modality AOSLO improves understanding of visual symptoms and photoreceptor structure changes in patients with head and ocular trauma.

Microsurgical repair of neonatal iliac artery injuries with saphenous vein grafts.

Two neonates with congenital heart disease, one and thirty-one days old respectively, suffered inadvertent arterial injury from cardiac catheterization. Both insults resulted in unrecognized avulsion of the external iliac artery from its origin. The patients quickly decompensated, with their right lower extremities becoming critically ischemic. In both cases, segments of reversed greater saphenous vein were used as interposition grafts from the common iliac artery to the common femoral artery. Reperfusion of the right foot was immediate for the one-day-old. She is now three years old and able to run, but is followed for a mild limb length discrepancy. The 31-day-old had restoration of flow to the right limb; however, the foot remained ischemic and eventually required transmetatarsal amputation. She is now 16 months old and able to crawl; she also is followed for limb length discrepancy. Without vein grafting, both infants would likely have lost their affected limbs, and possibly lost their lives. These cases advocate for microsurgical repair of arterial injuries in even the youngest patients, and promote the use of vein grafts when direct anastomosis is not feasible.