Efficacy of Abductor Pollicis Longus Suspensionplasty Compared to Ligament Reconstruction and Tendon Interposition.

Background: Multiple surgical techniques are described for basal joint osteoarthritis. This study compares clinical outcomes and patient satisfaction with trapeziectomy and abductor pollicis longus (APL) suspensionplasty compared to trapeziectomy with ligament reconstruction and tendon interposition (LRTI) when performed by 2 fellowship-trained hand surgeons. Methods: A retrospective review of 51 consecutive patients undergoing APL suspensionplasty (53 hands) was performed. With this technique, a distally based APL slip is brought through and sewn to the flexor carpi radialis (FCR). The remaining APL is placed in the trapeziectomy void. This technique was compared to 151 patients (166 hands) who underwent LRTI using the FCR tendon. Outcomes assessed included postoperative pain relief, grip and pinch strength, complications, and need for reoperation. Two-tailed, Fisher's exact test was used for data analysis. Results: APL suspensionplasty resulted in postoperative pain relief in 92.5% (n = 49) compared to 94.0% (n = 156) with LRTI (P = .758). Mean postoperative grip and pinch strengths with APL suspensionplasty were 41.2 and 10.4 kg, respectively. With LRTI, average grip strength was 42.0 kg, and pinch was 10.1 kg. Both techniques were well tolerated with minimal complications. In the APL group, 1 patient had a postoperative infection requiring drainage. Among the LRTI cases, 1 wound dehiscence required closure, and 2 minor postoperative wound infections resolved with oral antibiotics. Mean follow-up time among APL suspensionplasty patients was 3.3 months compared to 8.4 months following LRTI. Conclusions: APL suspensionplasty is a safe, effective procedure which provides similar pain relief and functional outcomes compared to LRTI.

Dermal Regeneration Template and Staged Skin Grafting for Extirpative Scalp Wound Reconstruction: A 14-Year Experience.

OBJECTIVE: Dermal regeneration template and staged split-thickness skin grafting may mitigate the need for flap coverage of postoncologic scalp defects. This technique has been studied previously in small case series. We examine the effect of risk factors, surgical technique, irradiation, and dressing modalities on reconstructive outcomes in a highly comorbid patient cohort. STUDY DESIGN: Retrospective review. SETTING: Academic medical center. METHODS: Full- and partial-thickness extirpative scalp wounds reconstructed with dermal regeneration template and staged skin grafting were reviewed over a 14-year period. Stage 1 consisted of template application following burr craniectomy in cases lacking periosteum. Stage 2 consisted of skin grafting. Negative pressure wound therapy (NPWT) was variably used to support adherence. RESULTS: In total, 102 patients were analyzed (average age 74, mean follow-up 18 months). Eighty-one percent were American Society of Anesthesiologists class 3 or 4. Defect size averaged 56 cm2. Average skin graft take was 94.5% in full-thickness wounds. Seven patients failed this method. Preoperative scalp irradiation was associated with major complication and delayed graft healing. Comorbidities, wound size, and burring were not associated with complication. Patients were more likely to heal with NPWT compared to bolster (hazard ratio, 1.67; 95% CI 1.01-2.77; P = .046). Time between stages was 6.6 days shorter when NPWT was applied (P < .001). CONCLUSION: Dermal template and staged skin grafting is a reliable option for postcancer scalp reconstruction in poor flap candidates. Radiotherapy is associated with adverse outcomes. Negative pressure wound therapy simplifies postoperative wound care regimens and may accelerate healing.

Use of Incisional Negative Pressure Wound Therapy in Skin-Containing Free Tissue Transfer.

BACKGROUND: Negative pressure wound therapy (NPWT) was initially introduced for wound management, but its benefits have stimulated the investigation of its use in new clinical scenarios. Most recently, incisional NPWT has been shown to be a benefit. Incisional NPWT applied to skin-containing free tissue transfer has not been well defined. This may originate from concerns of dressing material obscuring frequent examination of the newly transferred tissue or risk of pedicle compression and potential for increased risk of tissue loss. We aim to describe incisional NPWT in cutaneous free tissue transfer. METHODS: An institutional review board-approved retrospective review of consecutive free tissue transfer patients was completed over a 3-year period. Free tissue transfer procedures were performed in standard manner. After fixation of the flap to the donor site with interrupted sutures, one or two drainage tubes were inserted in the subflap position. The surface of the flap was protected with Vaseline gauze followed by a 1 cm thick layer of sterile cotton. The vacuum-assisted closure (VAC) sponge (KCI, TX) was then placed in the standard fashion and negative pressure at -125 mm Hg was initiated in a continuous mode. A window was routinely made over the flap's distal region to allow for serial flap examination. For extremity procedures, no splints were utilized, and patients were limited to motion in the hospital bed. NPWT was employed continuously for 7 days and subsequently removed along with operative drains. RESULTS: A total of 24 consecutive patients underwent free tissue transfer. The average patient age was 39.8 years with a mean body mass index of 23. Tobacco use was noted in 58% of patients in the series. The indication for the free tissue transfer included trauma (N = 21), malignancy (N = 2), and burn reconstruction (N = 1). The areas of reconstruction included scalp (N = 5), lower extremity (N = 11), and upper extremity (N = 8). Skin-containing free flaps employed consisted of the latissimus dorsi myocutaneous free flap (N = 16), anterolateral thigh free flap (N = 6), thoracodorsal artery perforator free flap (N = 1), and radial forearm free flap (N = 1). The average defect size reconstructed was 238.3 cm2 with a mean operative time of 501 minutes. Postoperatively, patients remained in the hospital an average of 15.5 days (range: 9-32 days) with a mean follow-up of 8.1 months. No hematomas, seromas, surgical-site infections, or deep vein thrombosis/pulmonary embolism occurred in the series. None of the flaps required return to the operating room. There were no documented cases of partial or complete flap loss. CONCLUSIONS: NPWT may be employed in a fashion similar to the standard incisional application. With this technique, serial flap examination remains possible and is not associated with pedicle compression or increased rates of flap loss. Interestingly, no splints were utilized with the VAC device which itself may serve as a relative immobilizer of an extremity.

The Impact of Biochemical Markers on Major Adverse Cardiovascular Events and Contralateral Carotid Artery Stenosis Progression Following Carotid Interventions.

BACKGROUD: To determine if elevated preintervention high-sensitivity C-reactive protein (hsCRP) and B-type natriuretic peptide (BNP) levels associate with major adverse cardiovascular events (MACE) or disease progression after carotid revascularization. METHODS: We retrospectively examined patients receiving elective carotid endarterectomy (CEA) or carotid artery stenting (CAS) at our institution from 2007 to 2014. All included patients had preintervention hsCRP and BNP levels. Examined outcomes of interest included contralateral carotid disease progression (increased stenosis or need for revascularization) and MACE (composite of death, stroke, myocardial infarction, need for coronary artery bypass graft or percutaneous coronary intervention) at 3 years after procedure. The relationship between baseline hsCRP and BNP levels and time to event was examined by univariate and multivariate Cox proportional hazard regression analyses. RESULTS: A total of 248 patients were included in the analysis (mean age: 68 ± 10 years), with 14% receiving CAS and 86% CEA. A total of 61 patients (25%) had 1 or more MACE by 3 years. Elevated hsCRP (>3 mg/L) trended toward associating with MACE but failed to reach significance (hazard ratio [HR]: 1.6 [1.0-2.7], P = 0.07). Multivariate analysis found that elevated BNP (>100pg/mL, HR: 2.2 [1.3-3.7], P = 0.002) and diabetes mellitus (HR: 1.9 [1.2-3.2], P = 0.01) predicted MACE. Having elevated preprocedural levels of both hsCRP and BNP significantly increased patients' likelihood of experiencing MACE (HR: 3.4 [1.6-7.1], P = 0.001). About 175 patients received contralateral carotid imaging postprocedure and of those patients, 31 (18%) experienced stenosis progression and/or revascularization within 3 years. However, neither elevated hsCRP (HR: 1.2 [0.6-2.3], P = 0.68) nor BNP (HR: 1.1 [0.5-2.5], P = 0.88) associated with disease progression. CONCLUSIONS: BNP elevation at the time of carotid intervention is associated with MACE in long-term follow-up. hsCRP does not appear to correlate with either disease progression of the contralateral artery or MACE.

The Integration of Adult Acute Care Surgeons into Pediatric Surgical Care Models Supplements the Workforce without Compromising Quality of Care.

Acute care of children remains a challenge due to a shortage of pediatric surgeons, particularly in rural areas. In our institutional norm, all cases in patients age six and older are managed by dedicated general surgeons. The provision of care to these children by these surgeons alleviates the impact of such shortages. We conducted a five-year retrospective analysis of all acute care pediatric surgical cases performed in patients aged 6 to 17 years by a dedicated group of adult general surgeons in a rural tertiary care hospital. Demographics, procedure, complications, outcomes, length of stay, and time of consultation/operation were obtained via chart review. Elective, trauma related, or procedures performed by a pediatric surgeon were excluded. Descriptive statistics are reported. A total of 397 cases were performed by six dedicated general surgeons during the study period. Mean age was 11.5 ± 3.1 years. In all, 100 (25.2%) were transferred from outlying facilities and 52.6 per cent of consultations/operations occurred at night (7P-7A), of which 33.2 per cent occurred during late night hours (11P-7A). On weekends, 34.0 per cent occurred. Appendectomy was the most commonly performed operation (n = 357,89.9%), of which 311 were laparoscopic (87.1%). Others included incision/drainage (4.5%), laparoscopic cholecystectomy (2.0%), bowel resection (1.5%), incarcerated hernia (0.5%), small bowel obstruction (0.5%), intra-abdominal abscess drainage (0.3%), resection of intussusception (0.3%), Graham patch (0.3%), and resection omental torsion (0.3%). Median length of stay was two days. Complications occurred in 23 patients (5.8%), of which 22(5.5%) were the result of the disease process. These results parallel those published by pediatric surgeons in this age group and for the diagnoses treated. Models integrating dedicated general surgeons into pediatric call rotations can be designed such that quality of pediatric care is maintained while providing relief to an overburdened pediatric surgical workforce.