A High Incidence of Perineal Post-Related Complications After Hip Arthroscopy Is Self-Reported by Patients in Anonymous Online Forums.

Purpose: To evaluate online, self-reported pudendal nerve or perineal injuries related to the use of a perineal post during hip arthroscopy. Methods: Public posts on Reddit and the Health Organization for Pudendal Education were searched to identify anonymous individuals reporting symptoms of pudendal nerve or perineal injury following hip arthroscopy. Included posts were by any individual with a self-reported history of hip arthroscopy who developed symptoms of pudendal nerve injury or damage to the perineal soft tissues. Demographic information and details about a person's symptoms and concerns were collected from each post. Descriptive statistics were used to analyze the data. Results: Twenty-three online posts reported on a perineal post-related complication following hip arthroscopy. Sex information was available in 16 (70%) posts (8 male, 8 female). Twenty-two posts reported a sensory injury, and 4 posts reported a motor injury with sexual consequences (sexual dysfunction, dyspareunia, impotence). Symptom duration was available in 15 (65%) posts (8 temporary, 7 permanent). Permanent symptoms included paresthesia of the perineum or genitals (7) and sexual complaints (5). Two posts stated they were counseled preoperatively about the possibility of this injury. Zero patients reported that a postless hip arthroscopy alternative was an option made available to them before surgery. Conclusions: A high incidence of permanent pudendal nerve, perineal skin, and genitourinary/sexual complications are self-reported and discussed online by patients who have undergone post-assisted hip arthroscopy. These patients report being uninformed and undereducated about the possibility of sustaining a post-related complication. No patient reported being informed of postless hip arthroscopy preoperatively. Clinical Relevance: Identifying and evaluating self-reported patient information in online medical forums can provide important information about patient experiences and outcomes.

Evaluation of Intraoperative Anastomotic Patency with Angiography in Microsurgical Breast Reconstruction.

Background: Microsurgical breast reconstruction is one of the most challenging, yet rewarding procedures performed by plastic surgeons. Several measures are taken to ensure safe elevation of the flap, preparation of recipient vessels, microvascular anastomosis, and flap inset. Reestablishing proper blood flow to the flap tissue after microvascular anastomosis is one of many critical steps for surgical success. Several measures to assess blood flow to the flap have been used; however, the use of indocyanine green angiography (ICGA) of the anastomosis in breast reconstruction has not been well documented. We present a series using ICGA for the evaluation of microvascular anastomosis success in breast reconstruction. Methods: Cases from patients who underwent microsurgical breast reconstruction between March 2022 and January 2023 and who had intraoperative ICGA were retrospectively reviewed. We compared the intraoperative findings on ICGA to flap success. Results: Sixteen patients underwent bilateral deep inferior epigastric perforator flap reconstruction with intraoperative ICGA of the microvascular anastomosis, constituting 32 deep inferior epigastric perforator flaps. The ICGA demonstrated return of blood flow in all the flaps after microvascular anastomosis and no flap loss in our sample population. Nine flaps required additional drainage using the superficial inferior epigastric vein, and the superficial circumflex vein was used for additional drainage in one of the flaps. Conclusions: The use of intraoperative ICGA provides reliable visual feedback regarding the patency and direction of the blood flow through the microvascular anastomosed vessels. ICGA can be used as an additional tool in the plastic surgeon's armamentarium for successful breast reconstruction.

The emerging role of MRI neurography in the diagnosis of chronic inguinal pain.

INTRODUCTION: Chronic pain is a frequent and notable complication after inguinal hernia repair, it has been extensively studied, but its management and diagnosis are still difficult. The cause of chronic pain following inguinal hernia surgery is usually multifactorial. This case series highlights the utility of MRI neurography (MRN) in evaluating the damage to inguinal nerves after a hernia repair, with surgical confirmation of the preoperative imaging findings. MATERIALS AND METHODS: A retrospective review was performed on patients who underwent inguinal mesh removal and triple denervation of the groin. Inclusion criteria included MRI neurography. All patients underwent surgical exploration of the inguinal canal for partial or complete mesh removal and triple denervation of the groin by the same senior surgeon. RESULTS: A total of nine patients who underwent triple denervation were included in this case series. MRN was then performed on 100% of patients. The postoperative mean VAS score adjusted for all patients was 1.6 (SD p), resulting in a 7.5 score difference compared to the preoperative VAS score (p). Since chronic groin pain can be a severely debilitating condition, diagnosis, and treatment become imperative. CONCLUSION: MRN can detect direct and indirect signs of neuropathy even in the absence of a detectable compressive cause aids in management and diagnosis by finding the precise site of injury, and grading nerve injury to aid pre-operative assessment for the nerve surgeon. Thus, it is a valuable diagnostic tool to help with the diagnosis of nerve injuries in the setting of post-inguinal hernia groin pain.

Feasibility for Immediate Targeted Muscle Reinnervation Based on Lower Extremity Amputations Trends.

Targeted muscle reinnervation has been adopted as a strategy for the management and prevention of phantom limb pain and symptomatic neuroma formation for patients undergoing lower extremity amputation. The procedure is often performed by surgeons different from those performing the amputation, creating scheduling dilemmas. The purpose of this study was to analyze historic trends in lower extremity amputation scheduling in a single hospital system to evaluate if offering routine immediate targeted muscle reinnervation is practical. Methods: De-identified data over a five-year period for all patients undergoing lower extremity amputation were collected. The data gathered included the specialty performing the amputation, weekly distribution of cases, start time, and end time, among others. Results: A total of 1549 lower extremity amputations were performed. There was no statistically significant difference in average number of below-the-knee amputations (172.8) and above-the-knee amputations (137.4) per year. Top specialties performing amputations were vascular surgery (47.8%), orthopedic surgery (34.5%), and general surgery (13.85%). No significant difference was noted in the average number of amputations across the week, per year. Most cases started between 6 am and 6 pm (96.4%). The average length of stay after surgery was 8.26 days. Conclusions: In a large, nontrauma hospital system, most lower extremity amputations are performed during typical working hours and are evenly distributed throughout the week. Understanding peak timing of amputations may allow for targeted muscle reinnervation to be performed concurrently with amputation procedure. Data presented will be a first step to optimizing amputation scheduling for patients in a large nontrauma health system.

Acetabular Paralabral Cyst Causing Obturator Nerve Compression in the Setting of Femoroacetabular Impingement Syndrome: A Case Report.

CASE: Large acetabular paralabral cysts can cause compression of the surrounding neurovascular structures leading to sensory and motor deficits. We present a 68-year-old man with obturator nerve denervation from a paralabral cyst secondary to a labral tear associated with femoroacetabular impingement syndrome. Resolution of symptoms and return to full activities were achieved at 3 months and maintained beyond 1 year through open cyst excision, obturator neurolysis, arthroscopic femoral osteoplasty, and labral repair in the same surgical setting. The patient had a successful clinical outcome, with pain and dysfunction resolution. CONCLUSION: Large paralabral cysts may cause obturator nerve compression, which can be successfully treated with open nerve decompression and arthroscopic treatment of labral pathology.

Targeted Muscle Reinnervation of the Supraclavicular Nerve to the Motor Branch of the Omohyoid Muscle in Patients Undergoing Thoracic Outlet Syndrome Procedures.

Transection of the supraclavicular nerve (SCN) through supraclavicular incisions can lead to debilitating neuroma formation. Targeted muscle reinnervation (TMR) proved to be an effective technique for the prevention and treatment of neuroma. In this case series, we propose the TMR of the SCN to the motor branch of the omohyoid muscle (OM) to prevent the formation of neuroma and avoid chronic pain at the supraclavicular area after thoracic outlet syndrome (TOS) procedures. A total of 10 patients underwent the procedure. Dissection of the SCN and its branches was performed through a supraclavicular incision. The branches were transected close to the clavicle. The inferior belly of the OM was identified and its motor branch isolated. Coaptation of the SCN branches with the motor branch of the OM was performed under the microscope and the wound was closed in layers. All the patients denied pain or hypersensitivity at the supraclavicular area on follow-up. In summary, the motor branch of the OM is a viable recipient for the TMR of the SCN and can prevent and treat painful neuromas at the supraclavicular area with minimal morbidity.

Does Surgeon Specialty Make a Difference in Ventral Hernia Repair With the Component Separation Technique?

Background Abdominal wall reconstruction (AWR) has evolved with the continued advent of new techniques such as component separation (CS). General (GS) and plastics surgeons (PS) are trained to perform this procedure. Differences in patient population and clinical outcomes between specialties are unknown. Methods Using a national database, patients who underwent incisional/ventral hernia repair managed with CS were grouped according to the primary specialty. Patient demographics, perioperative details, and postoperative complications were compared, and the risk factors associated with clinical outcomes were analyzed.  Results A total of 4,088 patients were identified. PS operated more often in the inpatient setting, and patients had a higher prevalence of hypertension and clean-contaminated wounds. Hypertension and being operated by a PS were associated with an increased risk of needing a blood transfusion after CST. Conclusion CS surgical outcomes are similar and comparable specialties. Primary specialty does not affect postoperative complications or 30-day mortality after CS.

Does Complexity Always Correlate With Compensation? An Analysis of Work Relative Value Units in 3 Common Nerve Decompression Syndromes.

BACKGROUND: Work relative value units (wRVUs) are part of Resource Based Relative Value Scale system. It is expected that a more difficult and time-consuming procedure would yield higher wRVUs. Brachial plexus nerve decompression surgery is a more time-consuming procedure compared with carpal and cubital tunnel procedures. The aim of this study was to analyze physician reimbursement in upper limb decompression procedures by comparing mean operative times, wRVUs per minute, and dollars per minute. METHODS: A retrospective cohort study was conducted from June 2016 to June 2019, including all patients who underwent carpal tunnel, cubital tunnel, and brachial plexus release procedures. Operating time was collected, and calculations of mean operative time, wRVUs per minute, and dollars per minute were performed and compared between groups. RESULTS: A total of 209 cases were included. Carpal tunnel accounted for 75.1% of the cases, followed by cubital tunnel and brachial plexus releases. Brachial plexus release had the highest median operative time (147 minutes), followed by cubital tunnel (57 minutes) and carpal tunnel release (16 minutes, P < 0.0001). Carpal tunnel release procedures had a significantly higher wRVUs per minute (0.310) when compared with cubital tunnel and brachial pleaxus release procedures, 0.127 and 0.077, respectively (P < 0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P < 0.0001). CONCLUSIONS: More complex and time-consuming procedures yielded a lower reimbursement for physicians. The current work relative unit system does not account adequately for the time spent in each procedure.

Post-Related Complications in Hip Arthroscopy Are Reported Significantly Greater in Prospective Versus Retrospective Literature: A Systematic Review.

PURPOSE: To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury. RESULTS: Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P < .001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively. CONCLUSIONS: The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries. LEVEL OF EVIDENCE: IV, systematic review of Level I-IV evidence.

Comparing plastic surgery and otolaryngology surgical outcomes and cartilage graft preferences in pediatric rhinoplasty: A retrospective cohort study analyzing 1839 patients.

ABSTRACT: Rhinoplasty in children has raised concerns about its safety in the pediatric population. There is scarcity of evidence describing outcomes and surgical techniques performed in pediatric rhinoplasty. We analyzed post-operative complications and cartilage preferences between plastic surgeons and otolaryngologists.Data was collected through the Pediatric National Surgical Improvement Program from 2012 to 2017. Current Procedure Terminology codes were used for data extraction. Patients were grouped according to type of rhinoplasty procedures (primary, secondary, and cleft rhinoplasty). A comparison between plastic surgeons and otolaryngologists was made in each group in terms of postoperative complications. Additionally, a sub-group analysis based on cartilage graft preferences was performed.During the study period, a total of 1839 patients underwent rhinoplasty procedures; plastic surgeons performed 1438 (78.2%) cases and otolaryngologists performed 401 (21.8%) cases. After analyzing each group, no significant differences were noted in terms of wound dehiscence, surgical site infection, readmission, or reoperation. Subgroup analysis revealed that plastic surgeons prefer using rib and ear cartilage, while otolaryngologists prefer septal and ear cartilage.The analysis of 1839 pediatric patients undergoing three types of rhinoplasty procedures showed similar postoperative outcomes, but different cartilage graft utilization between plastic surgeons and otolaryngologists.

Safety of Routine Pedicle Division during Delayed Breast Augmentation following Free Flap Breast Reconstruction.

BACKGROUND: Autologous free flap breast reconstruction is a common reconstructive procedure, with the ability to produce a natural breast shape and a long history of success. Despite its benefits, there are special situations in which patients lack sufficient donor-site tissue to achieve adequate breast size and projection. With this study, the authors describe their institutional experience of delayed implant augmentation after autologous breast reconstruction with a particular focus on pedicle division as a technique to improve aesthetic results. METHODS: A retrospective chart review of patients that underwent free flap autologous breast reconstruction with delayed implant augmentation was conducted over a 13-year period. Flaps were divided into a control group without pedicle division and a divided pedicle group. Groups were compared in terms of demographics, clinical and surgical characteristics, implant details, and postoperative implant and flap complications. RESULTS: No significant differences in terms of age, body mass index, comorbidities, radiation therapy, or surgical indications were noted. The most common reason for delayed implant augmentation after autologous breast reconstruction was change in breast size and breast asymmetry. In terms of implant and flap complications, we found no significant differences between the control and divided pedicle groups after delayed implant augmentation. CONCLUSIONS: From the authors' institutional experience, pedicle division in delayed breast augmentation with implants after free flap breast reconstruction can be safety performed in selected cases. This technique can be a powerful tool for plastic surgeons to improve the final aesthetic appearance of the reconstructed breast. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reoperative Cervical Endocrine Surgery: Appropriate Valuation for the Time and Effort?

BACKGROUND: Controversies currently exist regarding the best way to appropriately quantify complexity and to benchmark reimbursement for surgeons. This study aims to analyze surgeon reimbursement in primary and redo-thyroidectomy and parathyroidectomy using operative time as a surrogate for complexity. METHODS: A retrospective analysis using the National Surgical Quality Improvement Program database was performed to identify patients who underwent primary and redo-thyroidectomy and parathyroidectomy. Calculations of median operative time work relative value units per minute and dollars per minute were compared between primary and redo procedures. RESULTS: Thyroidectomy cases represented 53.5% (22,521 cases), and the other 46.5% (19,596 cases) were parathyroidectomy cases. The median dollars per minute in primary thyroidectomy was $4.97 and for redo-thyroidectomy was $8.12 (P < 0.0001). By the same token, dollars per minute were higher in the redo cases with $15.40 when compared with primary parathyroidectomy cases with $13.14 dollars per minute (P < 0.0001). CONCLUSIONS: By Current Procedural Terminology codes, surgeons appear to be appropriately reimbursed for redo-thyroid and parathyroid procedures indexed to first time parathyroidectomy based on the compensated operative time of these procedures calculated using a nationally representative sample.

Is Our Effort Appropriately Valued? An Analysis of Work Relative Value Units in Immediate Breast Reconstruction.

BACKGROUND: The work relative value units system was developed as a quantifier of physician labor, technical skill, and training time required to complete surgical procedures. Thus, more complex surgical procedures that require greater technical skills and are more time consuming should yield a greater compensation. It is known that prosthetic breast reconstruction reimburses more per hour than autologous breast reconstruction. However, there are limited data comparing work relative value units and operative times in breast reconstruction procedures. Therefore, this study aims to compare mean operative times and work relative value units per minute across three different modalities of breast reconstruction. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing implant-, pedicle-, and free flap-based reconstruction over a 6-year period. Calculation and comparison of median operative times, work relative value units, and dollars per minute was performed. RESULTS: A total of 3135 patients were included in the analysis: 2249 (71.7 percent) underwent immediate implant-based reconstruction, 745 (23.8 percent) underwent immediate free flap-based breast reconstruction, and 141 (4.5 percent) underwent immediate pedicle flap-based reconstruction. Patients were distributed in unilateral and bilateral cases. Consistently, median operative time was greater for free flap breast reconstruction, followed by pedicle flap- and implant-based reconstruction (p < 0.0001). However, work relative value units per minute and dollars per minute were found to be higher for prosthetic reconstruction in all comparisons (p < 0.0001). CONCLUSION: In the authors' analysis, more complex and time-consuming procedures resulted in a lower reimbursement in dollars and work relative value units per minute for the procedure.

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame.

There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.

Performance and Return to Sport After Femoroacetabular Impingement Surgery in National Football League Players.

The purpose of this study was to determine the (1) return-to-sport rate for National Football League (NFL) players following femoroacetabular impingement surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. National Football League athletes who underwent hip arthroscopy for femoroacetabular impingement and matched controls were identified. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007. Fifty-five players (63 surgeries) were analyzed (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). Forty-seven (53 surgeries, 84.1%) NFL players returned to sport at a mean of 6.7±3.8 months following surgery. There was no difference (P>.007) in the mean career length of players in the control group (3.7±2.2 years) vs players who underwent hip arthroscopy (3.5±2.1 years). There was no difference (P>.007) in mean games played per season of players in the control group (12.5±3.1) vs those who underwent hip arthroscopy (12.1±4.0). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007). The return-to-sport rate is high for NFL athletes after hip arthroscopy for femoroacetabular impingement. There were similar games per season and career lengths postoperatively compared with preoperatively and matched controls. Quarterbacks had significantly better postoperative performance when compared with matched controls. All other positions had similar postoperative performance compared with preoperatively and matched controls. [Orthopedics. 2019; 42(5):e423-e429.].

Absence of Stressful Conditions Accelerates Dexterous Skill Acquisition in Surgery.

The negative impact of strong sympathetic arousal on dexterous performance during formal surgical training is well-known. This study investigates how this relationship might change if surgical training takes place as a hobby in an informal environment. Fifteen medical students volunteered in a 5-week training regimen and weekly performed two standardized microsurgical tasks: circular cutting and simple interrupted suturing. Time was taken and two independent reviewers evaluated the surgical proficiency. The State Trait Anxiety Inventory (STAI) and the NASA Task Load Index (NASA-TLX) questionnaires measured subjective anxiety and workload, respectively. A high-resolution thermal imaging camera recorded facial imagery, from which a computational algorithm extracted the perinasal perspiration signal as indicator of sympathetic arousal. Anxiety scores on STAI questionnaires were indifferent for all five sessions. The continuously measured arousal signal from the thermal facial imagery was moderate and did not correlate with surgical proficiency or speed. Progressive experience was the strongest contributor to improved skill and speed, which were attained in record time. It appears that dexterous skill acquisition is facilitated by the absence of strong arousals, which can be naturally eliminated in the context of informal education. Given the low cost and availability of surgical simulators, this result opens the way for re-thinking the current practices in surgical training and beyond.

Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome.

Background: Thoracic outlet syndrome (TOS) is a complex entity resulting in neurogenic or vascular manifestations. A wide array of procedures has evolved, each with its own benefits and drawbacks. The authors hypothesized that treatment of TOS with first rib resection (FRR) may lead to increased complication rates. Methods: A retrospective case control study was performed on the basis of the National Surgical Quality Improvement Program database from 2005 to 2014. All cases involving the operative treatment of TOS were extracted. Primary outcomes included surgical and medical complications. Analyses were primarily stratified by FRR and secondarily by other procedure types. Results: A total of 1853 patients met inclusion criteria. The most common procedures were FRR (64.0%), anterior scalenectomy with cervical rib resection (32.9%), brachial plexus decompression (27.2%), and anterior scalenectomy without cervical rib resection (AS, 8.9%). Factors associated with increased medical complications included American Society of Anesthesiologists (ASA) classification of 3 or greater and increased operative time. The presence or absence of FRR did not influence complication rates. Conclusions: FRR is not associated with an increased risk of medical or surgical complications. Medical complications are associated with increased ASA scores and longer operative time.