Scaphoid Fractures Requiring Bone Graft: Does Graft Source Matter?

Background: Treatment of scaphoid fractures often requires bone grafting. In such cases, bone graft is traditionally harvested from the iliac crest, but utilizing the distal radius carries less morbidity and is becoming more popular. The purpose of this study is to compare the outcomes of treatment of scaphoid waist fractures with the use of distal radius and iliac crest bone grafts. Methods: A retrospective chart review of patients undergoing repair of a scaphoid waist fracture with bone graft at our institution between 2010 and 2020 was completed. Bone graft was used in patients with nonunion, humpback deformity, or for correction of scaphoid alignment. The primary outcome was rate of union as determined by postoperative X-ray or computed tomography scan. Fisher exact tests, Student t tests, and Mann-Whitney U tests were used as appropriate. Results: Thirty-nine patients were included in the study. Twenty-nine patients were treated with distal radius bone graft, and 10 were treated with an iliac crest graft. There was no statistical difference in union rate between the distal radius and iliac crest cohorts (97% vs 80%, P = .16). There was no significant difference for complication rates, rate of unplanned secondary surgery, time to union, postoperative scapholunate angle, or duration of immobilization. Conclusions: In the fixation of scaphoid waist fractures with bone graft, there is no significant difference in union rate between distal radius and iliac crest grafts. With the well-documented morbidity associated with iliac crest grafts, surgeons should consider using distal radius grafts instead of iliac crest grafts.

Bioabsorbable Temporizing Matrix (BTM): Not Just for Burns.

A skin substitute developed in Australia 2 decades ago for use in acute burns was recently introduced into the United States for the treatment of open wounds. This product has been shown to be very efficacious for coverage of debrided burn wounds. It consists of an inorganic synthetic woven layer that induces cellular ingrowth and deposition of interstitial tissue. It is covered by an attached silicone layer that seals the wound. The product is placed with the woven side directly on the wound. It is fixed in place and optimally covered by a negative pressure dressing for the first 5-10 days. Due to its synthetic composition, it is highly resistant to infection and can stay on the wound for as long as needed. The authors have used this matrix in a wide variety of complex reconstructions in 27 patients, consisting of 10 females and 17 males. Eleven had traumatic wounds of various etiologies (deep burns, crush injuries, Morell-Lavallee lesion, hand injuries, multiple trauma, open fractures, compartment syndromes and soft tissue avulsions). The following wounds were also treated with BTM: pressure ulcers, axillary hidradenitis, scalp wounds, severe facial acne keloidalis, Fournier's gangrene, a diabetic foot ulcer, a chronic venous ulcer, a cutaneous pyoderma gangrenosum, a radiation ulcer with exposed Achilles tendon, a disfiguring scar from an old Dupytrens excision and a non-healing chemotherapy extravasation ulcer. Hand and leg wounds with exposed tendon achieved coverage without tethering. The scalp wounds developed a neodermis and were skin-grafted. A pyoderma gangrenosum patient with excessive slough and uncontrolled bleeding was temporarily immunosuppressed, aggressively debrided and covered with the matrix. Her bleeding resolved. She developed a neodermis, and had reduced symptoms. The Fournier's patient had immediate skin-grafting of his penis and testicles, but the remaining extensive perineal and upper thigh wounds were treated with the matrix and healed without additional skin grafting. A hand patient with a forearm fasciotomy wound was covered with the matrix. As the swelling resolved the size of the defect decreased to the point that the wound was delaminated. The adjacent skin was elevated and used to cover the open area, achieving full closure. There were no complications attributed to the use of the matrix. Several patients healed secondarily with the silicone sheeting gradually peeling off. Seven patients have received or are awaiting skin grafts to be placed over the neodermis. Although this is an early review of the use of this synthetic matrix in the US, it comes with a positive legacy from Australia. The findings thus far indicate that there is a wide range of applications for this product well beyond burn care. Its safety record, resistance to infection and ease of use facilitate surgery.

Targeted Muscle Reinnervation in the Setting of Traumatic Bilateral Above-Knee Amputations: A Case Report.

CASE: We present the case of a 20-year-old man who was pedestrian struck and sustained bilateral traumatic above-knee amputations. Targeted muscle reinnervation (TMR) was performed with nerve transfers, including tibial nerve to semitendinosus (bilateral), superficial peroneal nerve to biceps femoris (left), deep peroneal nerve to biceps femoris (left), and common peroneal nerve to biceps femoris (right). CONCLUSIONS: Less than 1 year postoperatively, the patient was ambulating on his myoelectric prosthesis and experienced no Tinel or neuroma-type pain. This case is a testament to the impact TMR, an innovative surgical technique, can have on the quality of life of patients sustaining devastating limb injuries.

Discrepancies in Work Relative Value Unit Assignment Based on Operative Time in Hand Surgery.

BACKGROUND: Work relative value units (wRVUs) are an intricate component of physician reimbursement determination in the United States. This paper assesses whether wRVUs appropriately consider operative time in hand surgery. METHODS: The 50 most common single Current Procedural Terminology code hand surgery cases were queried from the 2013 to 2018 National Surgical Quality Improvement Program database. The average assigned wRVUs and median operative times were calculated for each CPT. Linear regressions were calculated between operative time, wRVUs, and wRVUs per hour. Cases deviating the most from the expected wRVUs based on operative time were identified. RESULTS: In all, 46 800 cases comprising the top 50 most common hand surgery procedures were identified. Among these cases, the median (range) assigned operative time was 62 minutes (18-110), wRVUs were 7.5 (3.5-18.0), and wRVUs per hour was 8.3 (4.9-14.2). There was a positive linear correlation between operative time and wRVUs (R2 = 0.60). Each additional operative hour was associated with an additional 6.3 wRVUs (P < .001). Based on this relationship, the assigned wRVUs for included cases ranged from 59.7% to 172.6% of expected. There was a weak negative relationship between wRVUs per hour and operative time (R2 = 0.25). Cases shorter than 1 hour had more wRVUs per hour than those longer than 1 hour (10.0 vs. 8.1, P = .003). However, this relationship disappeared when considering case turnover. CONCLUSION: This study suggests a moderately strong positive correlation between wRVUs and operative time in hand surgery. Yet, numerous outliers from this trend exist, suggesting some discrepancies in reimbursement.

Relative Value Units and Operative Time in Plastic and Reconstructive Surgery.

BACKGROUND: Work relative value units (wRVUs) are linked to clinical reimbursements and physician compensation in the USA and thus should consider the time of the physician providing care. The primary goal of this study is to assess whether wRVUs appropriately consider operative time in plastic and reconstructive surgery. METHODS: The 2015-2018 National Surgical Quality Improvement Program was queried for the 50 most performed plastic surgery cases with assigned wRVUs and a recorded operative time. Linear regressions were used to assess the relationships between operative time, assigned wRVUs, and wRVUs per hour. The procedures with the highest and lowest assigned wRVUs relative to their operative time were identified. RESULTS: A total of 31,156 cases were included in this analysis. Among the 50 most performed procedures, the median (range) for assigned wRVUs was 10.0 (1.0-42.6), operative time was 61 min (21-441), and wRVUs per hour was 8.7 (2.2-16.2). There was a strong positive linear correlation between assigned wRVUs and median operative time (R2=0.78), with each additional operative hour being associated with an increase of 5.3 wRVUs (p<0.001). The procedures earning the most wRVUs relative to their operative times were breast reconstruction with other techniques and tissue expander placement in breast reconstruction. However, excisional debridements of the muscle/fascia and subcutaneous tissue had the lowest earned wRVUs relative to their operative times. CONCLUSION: Although wRVUs and operative time are correlated in plastic surgery, numerous outliers from this trend exist. This suggests that wRVUs may not be optimally assigned across the range of plastic surgery procedures.

Secondary Autologous Fat Grafting as a Novel Method to Improve Pain and Appearance of the Residual Fingertip After Amputation.

Background: Adequate soft tissue coverage following distal phalanx amputation remains challenging. The purpose of this study was to evaluate patient-reported outcomes following secondary autologous fat grafting after reconstruction of distal phalanx amputations with tissue flaps. Methods: A retrospective review of patients who underwent autologous fat grafting to reconstructed fingertips following distal phalanx amputation with flaps from January 2018 to December 2020 was conducted. Exclusion criteria included patients who had amputations proximal to the distal phalanx or repair of distal phalanx amputations without flap closure. Data collected included patient demographics, mechanism of injury, complications, overall satisfaction, and outcomes of hyperesthesia, cold sensitivity, fingertip contour, and scarring reported using the Visual Analog Scale (VAS) before and after fat grafting. Results: Seven patients (10 digits) with fat grafting after transdistal phalanx amputations were included in the study. The average age was 45.1 ± 15.2 years. The mechanism of injury was crush in 6 patients and laceration in 1 patient. The average time between injury and fat grafting was 25.4 ± 20.6 weeks, and mean follow-up time after fat grafting was 2.9 ± 2.6 months. The mean improvement in VAS for hyperesthesia, cold sensitivity, fingertip contour, and scarring were 3.9 (P = .005), 2.8 (P = .09), 3.7 (P = .003), and 3.6 (P = .036), respectively. No intraoperative or postoperative complications were reported. Conclusions: This study demonstrates that secondary fat grafting after distal phalanx amputations previously reconstructed with flap closure is a safe method to improve patient- reported outcomes by decreasing hyperesthesia and cold sensitivity as well as improving scarring and patient perception of contour.

Distal Radius Salter-Harris III Transitional Fracture in an Adolescent Male.

In contrast to the well-described Tillaux fracture of the distal tibia, transitional fractures of the distal radius are exceedingly rare and have yet to be well described. Thus far, their presence in the literature has been limited to case reports and a singular series. None have involved a Salter-Harris III fracture pattern. We present the case of a 16-year-old male who sustained a Salter-Harris III transitional fracture of the distal radius with an associated ulnar styloid avulsion fracture secondary to a fall that was treated nonoperatively. Similar to the Tillaux fracture, examination of the distal radius transitional fracture should include computed tomography scan to better illustrate the pattern of injury and guide treatment.

Clinical Outcomes After Neurolysis for the Treatment of Peroneal Nerve Palsy: A Systematic Review and Meta-Analysis.

BACKGROUND: Neurolysis techniques have been adapted for decompression of peripheral nerves in multiple locations, including the common peroneal nerve (CPN) at the fibular neck. The aim of this study was to conduct a systematic review and meta-analysis to summarize the clinical outcomes of neurolysis for the management of peroneal nerve palsy (PNP). METHODS: Preferred Reporting Systems for Systematic Reviews and Meta-Analyses guidelines were followed for this meta-analysis. Four databases were queried, and randomized clinical trials, cohort studies, case-control studies, and case series with n > 10 published in English that evaluated clinical outcomes of neurolysis for the treatment of PNP and foot drop were included. Two reviewers completed screening and data extraction. Methodological quality was evaluated using the Newcastle-Ottawa Scale. RESULTS: A total of 493 articles were identified through literature search. Title and abstract screening identified 39 studies for full-text screening. Ten articles met the inclusion criteria for qualitative analysis, and 8 had complete data for meta-analysis.Overall, there were 368 patients (370 nerves) who had neurolysis of the CPN for PNP, of which 59.2% (n = 218) were men and 40.8% (n = 150) were women. The mean age of the patients was 47.1 years (SD, 10.0 years), mean time to surgery was 9.65 months (SD, 6.3 months), and mean follow-up time was 28 months (SD, 14.0 months). The median preoperative Medical Research Council (MRC) score was 1 (IQR 0, 3), with 42.2% (n = 156) having MRC score of 0. The median postoperative MRC score was 5 (IQR 4, 5), with 53.9% (n = 199) having MRC score of 5. Complications of neurolysis of the peroneal nerve for treatment of PNP included postoperative infection (0.54%, n = 2), wound dehiscence (0.27%, n = 1), hematoma (0.54%, n = 2), bleeding (0.27%, n = 1), relapse of PNP (0.27%, n = 1), and 1 case of mortality due to sepsis. CONCLUSIONS: Our meta-analysis shows that neurolysis of the CPN is safe and improves ankle dorsiflexion strength in patients with PNP. Future studies should use a standardized method of measuring sensory outcomes, and studies of higher levels of evidence are needed to better assess the clinical outcomes of neurolysis for treatment of PNP.

Panniculectomy Outcomes by Body Mass Index: an Analysis of 12,732 Cases.

PURPOSE: With an increasing rate of obesity in the USA, bariatric surgery has become widespread, resulting in a greater number of patients seeking panniculectomy. The authors aim to determine the complication profile of panniculectomies by body mass index (BMI). METHODS: The 2012-2018 National Surgical Quality Improvement Program database was queried for all panniculectomy cases. Patients were assigned to a category by their calculated BMI. Rates of complications were compared across BMI ranges. Demographics, comorbidities, and perioperative factors were compared between those with and without complications. Multivariable analyses were performed to analyze the associations between BMI ranges and post-surgical complications. RESULTS: Twelve thousand seven hundred thirty-two cases were analyzed, of which 1759 (13.8%) had at least one postoperative complication. As BMI increased, patients were more likely to experience postoperative complications (p<0.001). Patients experiencing complications were more likely to be male, older, of a higher BMI group, have a higher American Society of Anesthesiologists Personal Status classification, be an inpatient, have various comorbidities, or be undergoing a concurrent procedure. On multivariable analysis, patients who were overweight (OR=1.24, p=0.039), with class 1 (OR=1.72, p<0.001), class 2 (OR=2.10, p<0.001), or class 3 (OR=3.01, p<0.001) obesity were more likely to have a postoperative complication. Wound complications were particularly prevalent in patients who were overweight (OR=1.77, p=0.001) or with class 1 (OR=2.59, p<0.001), class 2 (OR=4.05, p<0.001), or class 3 (p=5.84, p<0.001) obesity compared to non-overweight patients. CONCLUSION: A higher BMI is associated with more postoperative complications, particularly wound healing complications, following panniculectomy in a dose-dependent manner.

Surgical prevention of terminal neuroma and phantom limb pain: a literature review.

The incidence of extremity amputation is estimated at about 200,000 cases annually. Over 25% of patients suffer from terminal neuroma or phantom limb pain (TNPLP), resulting in pain, inability to wear a prosthetic device, and lost work. Once TNPLP develops, there is no definitive cure. Therefore, there has been an emerging focus on TNPLP prevention. We examined the current literature on TNPLP prevention in patients undergoing extremity amputation. A literature review was performed using Ovid Medline, Cochrane Collaboration Library, and Google Scholar to identify all original studies that addressed surgical prophylaxis against TNPLP. The search was conducted using both Medical Subject Headings and free-text using the terms "phantom limb pain," "amputation neuroma," and "surgical prevention of amputation neuroma." Fifteen studies met the inclusion criteria, including six prospective trials, two comprehensive literature reviews, four retrospective chart reviews, and three case series/technique reviews. Five techniques were identified, and each was incorporated into a targetbased classification system. A small but growing body of literature exists regarding the surgical prevention of TNPLP. Targeted muscle reinnervation (TMR), a form of physiologic target reassignment, has the greatest momentum in the academic surgical community, with multiple recent prospective studies demonstrating superior prevention of TNPLP. Neurorrhaphy and transposition with implantation are supported by less robust evidence, but merit future study as alternatives to TMR.

Saved by the SPY: Ulnar Artery Reconstruction With LCFA Graft for Hypothenar Hammer Syndrome.

Introduction: Hypothenar Hammer syndrome refers to thrombosis/aneurysm of ulnar artery at Guyon's canal in wrist, with resultant arterial insufficiency in the ulnar artery distribution.1 Patients typically describe unilateral symptoms in the fourth and/or fifth fingers of the hand. Symptoms can range from asymptomatic to pain, pallor, paresthesia, weakness, cold intolerance, and eventually ulceration, necrosis, and gangrene of the distal digits.1 Treatment options range from conservative, lifestyle management, to medication, and ultimately to surgical intervention. In this case report, we outline the second successful lateral circumflex femoral artery (LCFA) graft reconstruction of the ulnar artery in the setting of Hypothenar Hammer Syndrome conducted by the senior author. However, during this procedure, the use of intraoperative intravenous (IV) injection of indocyanine green (ICG) dye (hereafter ICG) imaging helped identify an additional area of stenosis previously unseen on pre-operative MRA, therefore enabling us to perform a more adequate resection and repair. To our knowledge, the use of intraoperative ICG for Hypothenar Hammer Syndrome and/or ulnar artery reconstruction has not been documented in the literature.

Updates on and Controversies Related to Management of Radial Nerve Injuries.

Radial nerve injuries are among the most common major traumatic peripheral nerve injuries. Recent literature has updated our knowledge of aspects ranging from radial nerve anatomy to treatment options. Observation and tendon transfers were, and still are, the mainstays of management. However, the improved outcomes of nerve repair even 5 months after injury have changed the treatment algorithm. Nerve repair techniques using conduits, wraps, autograft, and allograft allow tension-free coaptations to improve success. Nerve transfers have evolved to allow a more anatomic recovery of function if used in a timely manner. This review offers an update on radial nerve injuries that reflects recent advances.

Mycobacterium phlei Vertebral Osteomyelitis.

A report of an instance of vertebral osteomyelitis secondary to an uncommon pathogen, Mycobacterium phlei. SUMMARY: Mycobacterium phlei is a rapidly growing nontuberculous osteomyelitis which is typically nonpathogenic with only four reported cases of human infection. Diagnosing infections related to nontuberculous mycobacteria (NTM) is difficult and can often be delayed as conventional microbiologic tests are inadequate. Currently, there are no consensus guidelines concerning the treatment of vertebral osteomyelitis caused by NTM. A 45-year-old man presented with chronic back pain and bilateral lower extremity radicular symptoms status-post lumbar fusion with previous deep infection. CT scan demonstrated incomplete union after fusion. He underwent irrigation and débridement on March 15, 2016, with tissue culture and biopsy. Given negative cultures and completion of a 6-week course of intravenous antibiotics, on May 3, 2016, he went for implant removal and repeat instrumentation. During the same hospitalization, deep spinal fluid acid-fast bacilli culture from March 15, 2016, came back positive at 8 weeks, identified as Mycobaterium phlei. He was started on an empiric 4-drug regimen for NTM which he continued for 12 months. There has been no recurrence of infection to date. DISCUSSION: This case serves as the first description of M. phlei osteomyelitis of the spine and as a reminder that proper diagnosis of infectious etiologies is necessary for adequate treatment.

The smaller isoforms of ankyrin 3 bind to the p85 subunit of phosphatidylinositol 3'-kinase and enhance platelet-derived growth factor receptor down-regulation.

The Src homology 2 (SH2) domains of the p85 subunit of phosphatidylinositol 3'-kinase have been shown to bind to the tyrosine-phosphorylated platelet-derived growth factor receptor (PDGFR). Previously, we have demonstrated that p85 SH2 domains can also bind to the serine/threonine kinase A-Raf via a unique phosphorylation-independent interaction. In this report, we describe a new phosphotyrosine-independent p85 SH2-binding protein, ankyrin 3 (Ank3). In general, ankyrins serve a structural role by binding to both integral membrane proteins at the plasma membrane and spectrin/fodrin proteins of the cytoskeleton. However, smaller isoforms of Ank3 lack the membrane domain and are localized to late endosomes and lysosomes. We found that p85 binds directly to these smaller 120- and 105-kDa Ank3 isoforms. Both the spectrin domain and the regulatory domain of Ank3 are involved in binding to p85. At least two domains of p85 can bind to Ank3, and the interaction involving the p85 C-SH2 domain was found to be phosphotyrosine-independent. Overexpression of the 120- or 105-kDa Ank3 proteins resulted in significantly enhanced PDGFR degradation and a reduced ability to proliferate in response to PDGF. Ank3 overexpression also differentially regulated signaling pathways downstream from the PDGFR. Chloroquine, an inhibitor of lysosomal-mediated degradation pathways, blocked the ability of Ank3 to enhance PDGFR degradation. Immunofluorescence experiments demonstrated that both small Ank3 isoforms colocalized with the lysosomal-associated membrane protein and with p85 and the PDGFR. These results suggest that Ank3 plays an important role in lysosomal-mediated receptor down-regulation, likely through a p85-Ank3 interaction.