Surgical Management of Vascular Malformations of the Upper Extremity: A 12-Year Retrospective Cohort Study.

INTRODUCTION: Vascular malformations (VMs) typically appear at birth and grow commensurately with patients. They can vary broadly in vessel type and tissue involvement, and upper extremity (UE) VMs can pose unique functional and aesthetic challenges in children. Given the advent of operative and nonoperative technologies like sclerotherapy and medications, a contemporary review of the surgical management of UE VMs is warranted. METHODS: We performed a retrospective review of all patients who had surgical management of VMs from 2010 to 2021 at The Children's Hospital of Philadelphia. Demographics, lesion characteristics, treatment (including preceding nonsurgical therapies), complications, and final outcomes were recorded. Operative notes were reviewed for date of operation, depth of excision, type of closure, and current procedural terminology code. RESULTS: Sixty-seven patients with 88 procedures were studied. Average patient age was 5.8 years, with 64% White and 67% male. Venous (34%) and lymphatic (19%) malformations were most common, and anatomic locations were most frequently on the hand (33%) and forearm (25%). The average lesion diameter was 4.2 cm, although this varied by location (eg, 2.9 cm, hand; 11.1 cm, chest wall). Fifty-eight patients (87%) underwent surgical excision as their index procedure, and 9 had sclerotherapy before surgery. Thirty-nine patients (60%) had subcutaneous excisions, and the remainder required subfascial or intramuscular excisions. Nearly all excisions were closed primarily (97%). Of the 53 patients with documented follow-up, 32 patients (60%) had complete resolution of their lesion as of their final visit. Thirty of these 32 patients with no clinical evidence of residual VM had only 1 surgery for excision. CONCLUSION: Upper extremity VMs were composed of diverse conditions with varying vessel types, size, depth, and anatomic sites. Surgical excision of VMs of the UE was safe and effective. A majority of VMs were fully excised after 1 procedure and frequently closed primarily with relatively low complication rates. Future work should investigate decision-making and outcomes of all treatment options of VMs of the UE for optimal functionality and aesthetics.

The Epidemiology, Management, and Outcomes of Civilian Gunshot Wounds to the Upper Extremity at an Urban Trauma Center.

Background: Gunshot wounds (GSWs) create significant morbidity in the United States. Upper extremity (UE) GSWs are at high risk of combined injuries involving multiple organ systems and may require variable treatment strategies. This study details the epidemiology, management, and outcomes of civilian UE GSWs at an urban level 1 trauma center. Methods: Using the University of Pennsylvania Trauma Registry, all adult patients with UE GSWs from 2015 to 2020 who were at least 6-months postinjury were studied for demographics, injury pattern, operative details, and postoperative outcomes. Fisher exact and Wilcoxon rank sum tests were used to determine differences in treatment modalities and outcomes. Results: In 360 patients, the most common victim was young (x̄ = 29.5 y old), African American (89.4%), male (94.2%), and had multiple GSWs (70.3%). Soft tissue-only trauma (47.8%) and fractures (44.7%) predominated. Presence of fracture was independently predictive of neurologic, vascular, and tendinous injuries (P < 0.001). Most soft tissue-only injuries were managed nonoperatively (162/173), whereas fractures frequently required operative intervention (115 of 161, P < 0.001). Despite a prevalence of comminuted (84.6%) and open (43.6%) fractures, hardware complications (7.5%) and wound infection (1.1%) occurred infrequently. Conclusions: Civilian GSWs to the UE with only soft tissue involvement can often be managed conservatively with antibiotic administration, bedside washout, and local wound care. Even with combined injuries and open fractures, single-stage operative debridement and fracture care with primary or secondary closure often prevail. As civilian ballistic trauma becomes more frequent in the United States, these data help inform patient expectations and guide management.

Upper Extremity Prosthetics: Current Options and Future Innovations.

Major upper extremity amputations can have a considerable impact on patients' lives, altering their ability to independently perform activities of daily living and leading to changes in occupations and hobbies. Although upper extremity prosthetics have existed for millennia, recent advances have improved prosthetic motor control and sensory feedback, leading to increased overall satisfaction. The goal of this article was to describe the current options that exist for upper extremity prosthetics and explore the recent advances and future directions in prosthetic technology and surgical techniques.

An Evolution of the Surgical Management of Synpolydactyly: A Case Series of 21 Hands.

INTRODUCTION: Synpolydactyly is a rare congenital anomaly characterized by syndactyly and polydactyly in the central hand. Limited treatment guidelines exist for this complex condition. METHODS: A retrospective review of synpolydactyly patients was conducted at a large, tertiary pediatric referral center to describe our surgical experience and evolution of management. The Wall classification system was used to categorize cases. RESULTS: Eleven patients (21 hands) with synpolydactyly were identified. Most of the patients were White and had at least one first-degree relative who also had synpolydactyly. The Wall classification yielded the following results: 7 type 1A hands, 4 type 2B hands, 6 type 3 hands, and 4 uncategorizable hands. Each patient had an average of 2.6 surgeries and an average follow-up time of 5.2 years. The rates of postoperative angulation and flexion deformities were 24% and 38%, respectively, with many of these cases also demonstrating preoperative alignment abnormalities. These cases often required additional surgeries including osteotomies, capsulectomies, and/or soft tissue releases. The rate of web creep was 14% with 2 of these patients requiring revision surgery. Despite these findings, at the time of final follow-up, most patients had favorable functional outcomes, were able to engage in bimanual tasks, and were able to perform activities of daily living independently. CONCLUSIONS: Synpolydactyly is a rare congenital hand anomaly with a significant degree of variability in clinical presentation. The rates of angulation and flexion deformities as well as web creep are not insignificant. We have learned to prioritize correcting contractures, angulation deformities, and skin fusion, over simply trying to delete the "extra" number of bones as this may destabilize the digit(s).

Opportunity Costs of Internal Promotions in Plastic Surgery: Are Women Given a Fair Shot?

Background: Academic advancement in plastic surgery necessitates creation of opportunities for rising faculty, which are pivotal for women in their efforts to close prominent gender gaps in higher ranks. We study positions of academic prestige that benefit from internal nomination as surrogates for opportunities afforded to men and women seeking leadership roles. Methods: We collected the following datapoints: authors of invited discussions published in Plastic and Reconstructive Surgery from 2010 to 2019; current editorial board members of representative plastic surgery journals; recipients of society-sponsored traveling fellowships; and directors of the American Board of Plastic Surgery. Public profiles for all authors and surgeons were referenced to confirm gender identification. Results: Seven-hundred ninety-seven plastic and reconstructive surgery discussions were included, 18% of which included female first or senior authorship. Seventy-one (9%) discussions listed a female senior author. Male and female senior authors were equally as likely to collaborate with a female first co-author (25% and 26%, respectively). Only 17% of invited authors contributed to 55% of discussion articles. Women occupied 19% of journal editorial board positions, though none were editors-in-chief. American Society of Reconstructive Microsurgery, American Society of Maxiliofacial Surgeons, American Society for Surgery of the Hand, and Plastic Surgery Foundation traveling fellowships were awarded to one (3%), four (7%), five (13%), and 141 (15%) female plastic surgeons, respectively. Women comprise 26% of directors of American Board of Plastic Surgery. Conclusions: Female representation in plastic surgery is rising, but it is not mirrored across appointed positions in academia. We should strive to support advancements that allow selected prestigious positions to more accurately reflect the gender distribution within the plastic surgery community.

Factors Influencing Why Children and Their Families Choose Surgery for Ganglion Cysts.

PURPOSE: Ganglion cysts of the hand/wrist are frequently managed without surgery but can be treated with surgical excision if there is pain or dysfunction. No studies have examined the specific factors predictive of surgical treatment for pediatric patients. METHODS: This was a study of pediatric patients (≤18 years) with ganglion cysts of the hand/wrist seen between 2017 and 2019 at 2 institutions. Baseline demographic data were collected in addition to cyst characteristics, Wong-Baker pain scores, and Patient-Reported Outcomes Measurement Information System scores (pain, depression, upper extremity function, anxiety). Multivariable regression was used to determine the factors predictive of surgical intervention at ≥6 months of eligible follow-up. RESULTS: A total of 167 patients with a mean age of 10.1 ± 5.3 years were included for analysis. Forty-three (25.7%) underwent surgical excision of their ganglion cyst at means of 2.3 months after the initial visit and 12.6 months after cyst appearance. Sex and cyst location were similar between cohorts. Surgical patients were older (12.1 vs 9.4 years, respectively) and presented to the clinic later after an appearance (10.9 vs 6.5 months, respectively) compared to nonsurgical patients. Surgical patients also had higher pain scores at presentation (median, 3 vs 0, respectively). Cysts receiving surgery were larger than those without surgery (81.4% vs 55.3% >1 cm, respectively). Pain interference Patient-Reported Outcomes Measurement Information System scores were higher in the surgical than the nonsurgical group (45.2 vs 39.6, respectively). In a multivariable analysis, pain scores ≥4 (odds ratio, 3.4) were predictive of surgery for patients ≥3 years, whereas older age (odds ratio, 1.1) and a cyst size >1 cm (odds ratio, 3.3) predicted surgery across all patients. CONCLUSIONS: Pediatric patients with ganglion cysts who initially present at older ages with moderate/severe pain scores and larger cysts are more likely to ultimately choose surgical excision. Surgeons may observe a preference for earlier surgery in this subset of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Does E-learning Improve Plastic Surgery Education?: A Systematic Review of Asynchronous Resources.

PURPOSE: E-learning is rapidly growing in medical education, overcoming physical, geographic, and time-related barriers to students. This article critically evaluates the existing research on e-learning in plastic surgery. METHODS: A systematic review of e-learning in plastic surgery was conducted using the PubMed/MEDLINE, Scopus, and Embase databases. Studies were limited to those written in English and published after 1995 and excluded short communications, letters to the editor, and articles focused on in-person simulation. RESULTS: A total of 23 articles were identified. Represented subspecialties include breast, burns, craniofacial/pediatrics, hand, and microsurgery. Most e-learning resources target surgeons and trainees, but a small number are for patients, parents, and referring physicians. Users reported high levels of satisfaction with e-learning and significant gains in knowledge after completion, although there may be more variable satisfaction with teaching technical skills. Two studies showed no differences in knowledge gains from e-learning compared with traditional learning methods. Subgroup analysis showed greater benefit of e-learning for novice learners when evaluated. Surveys of plastic surgeons and trainees showed high interest in and growing utilization of e-learning. CONCLUSIONS: Research in plastic surgery e-learning shows high user satisfaction and overall improvements in learning outcomes with knowledge gains equivalent to traditional teaching methods and greater benefit in novice learners. Thus, e-learning can serve an important role in plastic surgery education, especially in the current state of social distancing. Future work should aim to define learner preferences and educational needs and better establish how e-learning can augment plastic surgical education, particularly among other teaching methods.

Clinical Presentation and Characteristics of Hand and Wrist Ganglion Cysts in Children.

PURPOSE: Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort. METHODS: A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores. RESULTS: A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores. CONCLUSIONS: Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Effective Reduction in Opioid Prescriptions for Ambulatory Lesion Excisions in Pediatric Patients.

Childhood opioid consumption is potentially deleterious to cognitive development and may predispose children to later addiction. Opioids are frequently prescribed for outpatient surgery but may not be necessary for adequate pain control. We aimed to reduce opioid prescriptions for outpatient pediatric skin and soft tissue lesion excisions using quality improvement (QI) methods. METHODS: A multidisciplinary team identified drivers for opioid prescriptions. Interventions were provider education, improving computer order set defaults, and promoting non-narcotic pain control strategies and patient-family education. Outcomes included percentage of patients receiving opioid prescriptions and patient-satisfaction scores. Data were retrospectively collected for 3 years before the QI project and prospectively tracked over the 8-month QI period and the following 18 months. RESULTS: The percentage of patients receiving an opioid prescription after outpatient skin or soft tissue excision dropped significantly from 18% before intervention to 6% at the end of the intervention period. Patient-reported satisfaction with pain control improved following the QI intervention. Satisfaction with postoperative pain control was independent of closure size or receipt of a postoperative opioid prescription. Intraoperative use of lidocaine or bupivacaine significantly decreased the incidence of postoperative opioid prescription in both bivariate and multivariate analyses. Results were maintained at 18 months after the conclusion of the QI project. CONCLUSION: Raising provider awareness, educating patients on expected postoperative pain management options, and prioritizing non-narcotic medications postoperatively successfully reduced opioid prescription rates in children undergoing skin and soft tissue lesion excisions and simultaneously improved patient-satisfaction scores.

Searching for an Alternative Method to Evaluate Surgical Knowledge: Does a Drawing and Labeling Quiz Predict In-Service Exam Performance and Enhance Learning?

BACKGROUND: The best methods to assess surgical knowledge are still debated. The authors used a non-multiple-choice test as a pre- and post-conference assessment to measure residents' knowledge gains with comparison to a standard summative assessment tool. METHODS: At one didactic conference, plastic surgery residents at a single institution were given a pre-test of drawing and labeling structures in the extensor mechanism of the finger and within the carpal tunnel. The quiz was followed by a lecture on the same material and a subsequent post-test. Scores were correlated with in-service exam performance. RESULTS: Pre-test scores (n = 13) were positively correlated with postgraduate year (PGY) until PGY-3. Performance on labeling structures was higher than performance on the respective drawing prompt. Residents' ability to label structures increased more strongly with PGY than their ability to draw structures. The post-test (n = 8) demonstrated that teaching improves performance on labeling questions (pre-test score = 62%; post-test score = 87%). Improvement was observed across all PGYs. Pretest results were positively correlated with in-service exam performance. CONCLUSIONS: Our study suggests that a knowledge test focused on drawing and labeling structures given to surgical residents is a valid, nontraditional method for assessing resident knowledge. Such a quiz would offer programs an alternative method for regularly evaluating residents aside from in-service questions, in order to identify residents who may need targeted training for the in-service exam and to inform teaching plans.Additionally, residents could use quiz feedback to guide study efforts and prime conference-related learning.

A Systematic Review of Sensory Outcomes of Digital Nerve Gap Reconstruction With Autograft, Allograft, and Conduit.

BACKGROUND: Direct comparison of nerve autograft, conduit, and allograft outcomes in digital nerve injuries is limited. This study aims to compare the outcomes of nerve autografts, allografts, and conduits relative to primary repair (PR) through a systematic review. METHODS: A review of literature related to digital nerve gap repairs was conducted using PubMed/MEDLINE. Included articles were human clinical studies on digital nerve injuries repaired with nerve autograft, allograft, bovine collagen conduit, or PR. Patient characteristics, injury details, and complications were collected. Greater than 6-month outcomes included static 2-point discrimination, the British Medical Research Council Scale, or Semmes-Weinstein. RESULTS: Four autograft, 4 allograft, 5 conduit, and 7 PR publications were included. Allografts had the most repairs (100%) with static 2-point discrimination less than 15 mm, followed by autografts (88%), conduits (72%), and PR (63%). In British Medical Research Council Scale results, autografts (88%) and allografts (86%) were similar for patients with at least S3+ sensibility, compared to conduit (77%) and PR (39%). For Semmes-Weinstein, autografts demonstrated 93% normal sensation or diminished light touch, compared to allografts (71%), PR (70%), or conduits (46%). Conduits had the highest complication rate (10.9%), followed by autografts (5.7%), allografts (3.0%), and PRs (0.4%). CONCLUSIONS: Although a randomized clinical trial would provide strongest evidence of superiority, this review presents the highest percentage of patients with normal to near normal sensory recovery in allograft and autograft repairs with low rates of complications. Nerve conduit studies reported a higher rate of incomplete recovery of sensation and complications.

Partial Hand Transplant: Lessons Learned From Cadaveric Dissection Studies.

As the field of vascularized composite allotransplantation continues to expand, new upper extremity transplant candidates are being considered. We recently evaluated a bilateral amputee who had a mid-forearm amputation and a contralateral metacarpal hand amputation. In the latter limb, a "partial" hand transplant that preserved the majority of the patient's existing hand, including a partially severed thumb with intact thenar muscle function, was proposed. The feasibility of this partial hand transplant was studied in fresh-frozen cadaver limbs. This report details the proposed approach, the cadaveric dissections, and the lessons learned from these dissections. Issues of osteosynthesis, microvascular planning, and intrinsic muscle recovery are discussed, all of which are critical considerations for partial hand transplant candidates. Ultimately, the partial hand approach was felt to be inferior to a more conventional distal forearm transplant in this particular candidate. Practical, functional, and ethical implications of such decision are presented.

Radial Longitudinal Deficiency: Recent Developments, Controversies, and an Evidence-Based Guide to Treatment.

Radial longitudinal deficiency (RLD) is the most common congenital longitudinal deficiency at birth and represents a wide spectrum of upper extremity anomalies, from mild thumb hypoplasia to absent radius. Radial dysplasia may be isolated or associated with an array of systemic anomalies that should be familiar to pediatric hand surgeons. The management of RLD has evolved greatly since its inception in the late 19th century, largely due to decades of innovation that followed the thalidomide catastrophe of the 1960s. Yet controversy still exists regarding many aspects of RLD. Traditional treatments of radial dysplasia (ie, centralization) are unfortunately wrought with poor outcomes and high rates of recurrence, leading some authors to recommend alternative techniques for this condition. Reconstruction of the hypoplastic thumb, although less controversial, is just starting to see long-term outcomes. This article reviews the etiology, classification, and treatment options for RLD, highlighting recent developments and outcomes.

Clinical Characteristics of Pyogenic Flexor Tenosynovitis in Pediatric Patients.

PURPOSE: To characterize the clinical presentation, common pathogens, antimicrobial susceptibility, and treatment methods associated with pyogenic flexor tenosynovitis (PFT) in pediatric patients. METHODS: Patients who underwent surgical treatment for PFT at a large tertiary-care children's hospital between 2001 and 2015 were identified. Descriptive summary statistics were reported on patient demographics, presenting symptoms and clinical examination features, culture results, treatment strategies, and early complications. RESULTS: Thirty-two patients (71.9% male) with a mean age of 9.5 ± 5.5 years (range, 0.8-19 years) were included. At least 3 Kanavel signs were present on presentation in 62% of the cohort, with all 4 signs identified in 34%. Three children (9%) presented with 0 to 1 Kanavel signs, with semiflexed posturing of the digit as the least commonly (41%) manifested sign. The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (MRSA) (38%), methicillin-sensitive S. aureus (22%), and Pasteurella multocida (13%). Multiple organisms were cultured in 19% of cases. Intravenous antibiotics were administered for a median duration of 4 days (range, 1-16 days) in all cases. Organisms were sensitive to the initial antibiotic regimen in 81% of cases. All methicillin-resistant S. aureus infections were sensitive to vancomycin and trimethroprim-sulfamethoxazole, and 83% were sensitive to clindamycin. Incision and drainage (I&D) was performed in all cases, with 18% of patients requiring repeat I&D. Surgical approaches included limited incision (80%), midaxial incision (13%), and Bruner incision (7%). The average length of hospitalization was 5.1 days. Infection resolved in all cases without readmission. No neurovascular complications were identified. CONCLUSIONS: The presence of Kanavel signs at presentation are a meaningful indicator of PFT, but are not uniformly present on examination in children and adolescents. Owing to the prevalence of antimicrobial resistance and polymicrobial infection, empirical antibiotic therapy using broad-spectrum agents with MRSA coverage is essential. In our cohort of pediatric patients with PFT of sufficient severity to warrant surgical management, prompt I&D along with culture-guided antibiotics predictably resolves infection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Gender Authorship Trends of Plastic Surgery Research in the United States.

BACKGROUND: An increasing number of women are entering the medical profession, but plastic surgery remains a male-dominated profession, especially within academia. As academic aspirations and advancement depend largely on research productivity, the authors assessed the number of articles authored by women published in the journal Plastic and Reconstructive Surgery. METHODS: Original articles in Plastic and Reconstructive Surgery published during the years 1970, 1980, 1990, 2000, 2004, and 2014 were analyzed. First and senior authors with an M.D. degree and U.S. institutional affiliation were categorized by gender. Authorship trends were compared with those from other specialties. Findings were placed in the context of gender trends among plastic surgery residents in the United States. RESULTS: The percentage of female authors in Plastic and Reconstructive Surgery increased from 2.4 percent in 1970 to 13.3 percent in 2014. Over the same time period, the percentage of female plastic surgery residents increased from 2.6 percent to 32.5 percent. By 2014, there were more female first authors (19.1 percent) than senior authors (7.7 percent) (p < 0.001). As a field, plastic surgery had fewer female authors than other medical specialties including pediatrics, obstetrics and gynecology, general surgery, internal medicine, and radiation oncology (p < 0.05). CONCLUSIONS: The increase in representation of female authors in plastic surgery is encouraging but lags behind advances in other specialties. Understanding reasons for these trends may help improve gender equity in academic plastic surgery.

Assessing Surgical and Medical Complications in Bilateral Abdomen-Based Free Flap Breast Reconstructions Compared With Unilateral Free Flap Breast Reconstructions.

BACKGROUND: Prophylactic mastectomy is more common, with many patients seeking reconstruction. Bilateral free flap reconstructions subject patients to 2 flaps and longer operations, potentially increasing their risk for complications. We hypothesized that bilateral abdomen-based free flap reconstruction patients are a unique patient population with a higher rate of perioperative complications. METHODS: A retrospective chart review compared all 444 bilateral abdomen-based free flap breast reconstructions (in 222 patients) and 367 unilateral free flap breast reconstructions, performed at a single institution between March 2005 and July 2011. Patient and surgical characteristics and complications were studied. RESULTS: Bilateral reconstruction patients were slightly younger and heavier (mean, 49.2 years and 77.7 kg) and more likely to be white. Bilateral reconstructions were more often immediate reconstructions and less likely to have postoperative radiation therapy. These patients had longer surgical times and higher rates of intraoperative arterial thrombosis, but there were no significant differences in postoperative thrombosis or flap loss rates between the groups. The bilateral reconstruction patients, however, did have higher rates of minor surgical and medical complications, including a higher rate of lower extremity deep venous thrombosis (1.8% vs 0.3%, P = 0.045). CONCLUSIONS: We find that bilateral abdomen-based free flap breast reconstruction patients do not have higher rates of major postsurgical complications such as flap loss or postoperative thrombosis. However, higher rates of minor surgical and postoperative medical complications, including significantly more cases of lower extremity deep venous thrombosis, are seen. These findings are important for patient counseling and perioperative management.