Surface Electromyography-Driven Therapeutic Gaming for Rehabilitation of Upper Extremity Weakness: A Pilot Study.

SUMMARY: In patients with severe upper extremity weakness that may result from peripheral nerve injuries, stroke, and spinal cord injuries, standard therapy in the earliest stages of recovery consists primarily of passive rather than active exercises. Adherence to prescribed therapy may be poor, which may contribute to suboptimal functional outcomes. The authors have developed and integrated a custom surface electromyography device with a video game to create an interactive, biofeedback-based therapeutic gaming platform. Sensitivity of the authors' custom surface electromyography device was evaluated with simultaneous needle electromyography recordings. Testing of this therapeutic gaming platform was conducted with a single 30-minute gameplay session in 19 patients with a history of peripheral nerve injury, stroke, spinal cord injury, and direct upper extremity trauma, including 11 patients who had undergone nerve and/or tendon transfers. The device was highly sensitive in detecting low levels of voluntary muscle activation and was used with 10 distinct muscles of the arm, forearm, and hand. Nerve and tendon transfer patients successfully activated the donor nerve/muscle and elicited the desired movement to engage in gameplay. On surveys of acceptability and usability, patients felt the system was enjoyable, motivating, fun, and easy to use, and their hand therapists expressed similar enthusiasm. Surface electromyography-based therapeutic gaming is a promising approach to rehabilitation that warrants further development and investigation to examine its potential efficacy, not only for building muscle strength and endurance but also for facilitating motor relearning after nerve and tendon transfer surgical procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Occult primary breast cancer presenting with brachial plexopathy: A case report.

Breast cancer affects about one in eight women over the course of her lifetime. Occult breast cancer, in which primary breast cancer is detected without evidence of disease in the breast itself, comprises up to 1% of new diagnoses; this is typically detected from abnormal axillary lymph nodes, and distant metastases are rare. Here, we present an unusual case of occult breast cancer presenting as upper extremity pain, edema, and weakness, with a metastatic mass to the brachial plexus being the only site of disease.

Resident experiences with virtual education during the COVID-19 crisis.

BACKGROUND: Residency education has adapted to current social distancing recommendations by relying heavily on videoconferences. There is concern however, that this new paradigm may lead to over-saturation or burnout. METHODS: A 12-question survey investigating resident experiences with educational videoconferences was distributed to University of Washington plastic surgery residents. A modified Maslach Burnout Inventory was used to assess resident burnout from virtual conferences. Conference attendance and reasons for missing conferences were compared using paired two-tailed t-tests. RESULTS: A total of 24 residents were given the survey with 100% response rate. There was a significant decrease in the total number of weekly attended videoconferences (p<0.01) and in the number of attended educational videoconferences (p<0.01) over time. Reasons for absences included clinical duties (92% of respondents) followed by symptoms of burnout, including forgetfulness (67%) and feeling fatigued by videoconferencing lectures (54%), and to a lesser extent the belief that the lecture was not educational (25%). 79% of residents reported at least occasionally feeling emotionally drained from videoconferencing and 88% reported at least occasionally feeling burned out due to the number of videoconferencing activities. Despite declining attendance and burnout, 96% believe that videoconferences should continue after the end of quarantine but in a limited quantity. CONCLUSION: Videoconferences have become a valued means of resident education. The data suggests however that attendance has waned, largely due to what can be perceived as burnout. Residents remain interested in continuing educational videoconferences, although prioritizing quality over quantity will remain essential to prevent emotional fatigue and burnout.

Assessment of Plastic Surgery Residency Applications without United States Medical Licensing Examination Step 1 Scores.

SUMMARY: The United States Medical Licensing Examination announced the changing of Step 1 score reporting from a three-digit number to pass/fail beginning on January 1, 2022. Plastic surgery residency programs have traditionally used United States Medical Licensing Examination Step 1 scores to compare plastic surgery residency applicants. Without a numerical score, the plastic surgery residency application review process will likely change. This article discusses advantages, disadvantages, and steps forward for residency programs related to the upcoming change. The authors encourage programs to continue to seek innovative methods of objectively and holistically evaluating applications.

Hand Trauma Network in the United States: ASSH Member Perspective Over the Last Decade.

PURPOSE: Upper extremity trauma is common, however the provision of emergency call for hand trauma can be challenging for hospital systems and hand surgeons. Over the past decade, the American Society for Surgery of the Hand (ASSH) has developed the Hand Trauma Network and an Emergency Hand Care Committee to refine care for hand trauma patients. METHODS: The ASSH administered surveys to members about the provision of emergency hand call in 2010 and 2019. Demographic information was collected including surgeon age, years in practice, board certification, practice setting, and ACS trauma level. Other survey questions included willingness and obligation to take call, as well as barriers to providing emergency call. Financial aspects of call were also queried. RESULTS: Survey responses were obtained from 672 surgeons in 2010 and 1005 surgeons in 2019. There was a decrease in surgeons with obligatory hand call from 2010 to 2019 (70% vs 50%, P < .05) and an increase in the number of surgeons not taking hand call in 2019 (34%) compared to 2010 (18%, P < .05). In both surveys, the main barrier for providing hand call was "lifestyle considerations," 39% (2010) and 47% (2019). There was no change in the percentage of surgeons working at facilities that provide 24/7 emergency hand call services or the percentage of hand surgeons paid to take call. CONCLUSIONS: Certain aspects of providing emergency hand surgery care have not changed substantially in the past decade, including the number of centers that provide emergency hand coverage. A greater number of surgeons are not taking any hand call. Further efforts are required to promulgate advances in hand trauma call by the ASSH. CLINICAL RELEVANCE: The development of the ASSH Hand Trauma Network has not yet resulted in substantive improvement in the number of facilities that provide emergency hand coverage or the number of hand surgeons providing emergency hand care.

Globalization of The Journal of Craniofacial Surgery Over The Last Decade: A Continent, Country, and State Level Analysis.

ABSTRACT: Craniofacial surgery continues to be a rapidly evolving field, due in part to interdisciplinary collaboration that has allowed for sharing of knowledge and methodologies, which has expanded greatly due to online journals and publications. The Journal of Craniofacial Surgery (JCS) is a highly regarded journal that has attracted attention for its mission to increase diversity and global representation in manuscript submissions and research publications. The purpose of this study is to provide an objective measurement of global participation in craniofacial research specifically as it pertains to the JCS. Through a bibliometric analysis, the country of origin of all articles published in the JCS from 2010 to 2019 was analyzed. In line with its mission, the JCS increased its overall production 1.9 times during the past decade and increased its global representation 1.6 times, as represented by the number of countries contributing (78). The journal produced 8147 articles with Turkey (1424), USA (1397), China (1178), South Korea (1023), and Italy (644) being the top producers. The highest represented states were Florida (156), New York (130), California (117), Massachusetts (112), and Pennsylvania (106). The Journal of Craniofacial Surgery has the greatest diversity of country representation of the major plastic and reconstructive journals compared. Overall the JCS has stayed true to its mission to foster craniofacial research and is a valuable resource for craniofacial surgeons across the world. This study provides an analysis of trends in global contributions to craniofacial research and highlights areas for further increasing global contributors to the field of craniofacial surgery.

Severe Fireworks-Related Injuries: Demographic Characteristics, Injury Patterns, and Firework Types in 294 Consecutive Patients.

OBJECTIVES: The relationship between fireworks and patient characteristics is not known. Our objective was to examine how severe fireworks-related injuries in children and teens compare to adults. METHODS: We conducted a retrospective case series (2005-2015) study of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or operation at a single level 1 trauma/burn center. The distribution of race, use behavior, injury type, body region injured, and firework type was examined by age groups, 1 to 10 years, 11 to 17 years, and 18 years or older. RESULTS: Data from 294 patients 1 to 61 years of age (mean, 24 years) were examined. The majority (91%) were male. The proportion of injuries from different firework types varied by age, with rockets causing the highest proportion in children aged 1 to 10 years, homemade fireworks in those aged 11 to 17 years, and shells/mortars in adults 18 years or older. Compared with adults, children aged 1 to 10 years were more frequently American Indian/Alaska Native, Hispanic, or Asian than White. Compared with adults, children aged 1 to 10 years and 11 to 17 years were more frequently bystanders than active users. Compared with adults, children aged 1 to 10 years and 11 to 17 years had a greater proportion of burn and face injuries. Children aged 1 to 10 years had a decreased proportion of hand injuries. Three patients, 2 adults and 1 child aged 11 to 17 years, died. CONCLUSIONS: Children, teens, and adults experience severe fireworks-related injuries differently, by demographic characteristics, injury patterns, and firework types. Tailored public health interventions could target safety messaging and injury prevention outreach efforts to reduce firework injuries among children and adolescents.

Closed Ring Avulsion Injury With Isolated Arterial Insufficiency.

Ring avulsion injuries are an uncommon, often catastrophic, pattern of digit injuries that result from sudden traction onto a ring-bearing digit. The reconstructive treatment of these injuries can be complex because of the characteristic involvement of nerves, muscles, vasculature, and bone. There is paucity of literature describing isolated arterial injuries in the absence of overlying soft tissue and underlying bone involvement. We present an unusual case of a closed ring avulsion injury, wherein a patient initially presented to his local urgent care center with a cool and pale digit without wounds or fractures, and abnormal pulse oximetry readings prompted his transfer to a tertiary care center for further evaluation. Surgical exploration demonstrated isolated disruption of both digital arteries and the preservation of both digital nerves. The digit was successfully revascularized with venous autografting and stripping of arterial thrombi.

A Review of Hand Feminization and Masculinization Techniques in Gender Affirming Therapy.

INTRODUCTION: Anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria. Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands. This review is intended to cover the anatomical features that define masculine and feminine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand, and to adapt established aesthetic hand techniques for gender affirming care. METHODS: The authors performed a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of masculine or feminine hands, hand treatments related to gender affirmation, and articles related to techniques for hand masculinization and feminization in the non-transgender population. RESULTS: From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search. There is currently no medical literature specifically exploring the surgical or non-surgical options for hand gender affirmation. The available techniques for gender affirming procedures discussed in this paper are appropriated from those more commonly used for hand rejuvenation. CONCLUSION: There is a dearth of literature addressing the options for transgender individuals seeking gender affirming procedures of the hand. Though established procedures used for hand rejuvenation may be utilized in gender affirming care, further study is required to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. .

A Picture of Modern Medicine: Race and Visual Representation in Medical Literature.

BACKGROUND: There has been a recent focus on the impact of race on health equity, which has revealed unsettling results. Multiple studies have shown that the underrepresentation of minorities in medical education such as course slides, pre-clinical lecture material, case studies, and textbooks impedes racial equity in the practice of medicine. AIM OF STUDY: In this study, we aimed to survey the landscape of published imaging in modern medicine to understand the degree of racial diversity represented in current biomedical literature. METHODS: We performed a photogrammetric analysis of medical images from the New England Journal of Medicine representing various medical fields and geographic regions to examine implicit biases with regards to human skin color. RESULTS: Overall, 18% of images depicted non-white skin tone but there was considerable heterogeneity in the percentage of non-white medical images published from different geographic regions and specialties (ranging from 0% to 67%). CONCLUSIONS: Unfortunately, these results suggest that there is an underlying implicit racial bias in published images from medical literature with an underrepresentation of minorities compared to the general population, which could also contribute to inequities in health care. It is critical that health care providers, educators, and trainees promote cultural competency and work to understand the multifaceted influence of race and culture on the daily experience of patients in the modern healthcare system. We hope this study will encourage authors to critically evaluate their medical images for implicit bias so that documented photography in scientific literature may better reflect the populations we serve.

Globalization of Plastic and Reconstructive Surgery: A Continent, Country, and State-Level Analysis of Publications.

Over the past decade, there has been a worldwide increase in plastic and reconstructive surgery research as well as increased interest in global collaboration. However, little is known about who is contributing to this global expansion or the trends of individual countries. The aim of our study was to analyze the output of Plastic and Reconstructive Surgery (PRS) over a decade to elucidate trends in the plastic surgery field. METHODS: The country of origin for all first authors of articles published by PRS from 2010 to 2019 were determined and date extracted using PubMed2XL. The change in frequency of publications over the decade by country, continental contributions, as well as state-level analysis within the United States were analyzed. RESULTS: From 2010 to 2019, there were a total number of 8680 publications with an increase in total articles from 747 to 1049 per year. 54 countries contributed over the decade, with the United States producing the most followed by Italy, China, Canada, and the UK. The top producing states were Texas, New York, California, Massachusetts, and Pennsylvania. CONCLUSIONS: The last decade (2010-2019) saw a large international increase in research, not only with the total number of publications, but also in the diversity of originating country. Our work shows a shift away from a US-focused journal to incorporate more work from our international colleagues, as research is conducted in centers across the globe.

The Early Effects of COVID-19 on Plastic Surgery Residency Training: The University of Washington Experience.

Plastic surgeons have the unique perspective of working with all types of patients and care teams from almost all specialties in surgery and medicine, which creates unique challenges in times of distress. As the initial epicenter of coronavirus disease 2019 cases in the United States, the University of Washington program was required to rapidly develop strategies to deal with the escalating crisis. All aspects of the program were affected, including the need to triage the urgency of plastic surgery care, safe staffing of plastic surgery teams, and the role of plastic surgery in the greater hospital community. In addition, as a residency training program, limiting the impact of resident education and maintaining a sense of community and connection among members of the program developed into important considerations. The authors hope that the narrative of their experience will provide insight into the decisions made in the University of Washington health care system but also remind others that they are not alone in dealing with the challenges of this pandemic.

Prospective Quality-of-Life Outcomes after Facial Feminization Surgery: An International Multicenter Study.

BACKGROUND: No data exist on the prospective outcomes of facial feminization surgery. This study set out to determine the effects of facial feminization surgery on quality-of-life outcomes for gender-diverse patients. METHODS: A prospective, international, multicenter, cohort study with adult gender-diverse patients with gender dysphoria was undertaken. Facial feminization outcome score was calculated preoperatively and postoperatively (1-week to 1-month and >6 months). Photogrammetric cephalometries were measured at the same time points. Self-perceived preoperative masculinity and femininity were recorded. Externally rated gender appearance (scale of 1 to 5, with 1 being most feminine) and general aesthetics (scale of 1 to 10, with 10 being very good) for 10 facial feminization surgery patients were compared with those of five cisgender controls. Univariate linear regression analyses were used to predict outcomes from facial feminization surgery. RESULTS: Sixty-six consecutive patients were enrolled. Patients noted that their brows, jaws, and chins were the most masculine aspects of their faces (54.5 percent, 33.3 percent, and 30.3 percent, respectively). Median facial feminization outcome score increased from 47.2 preoperatively to 80.6 at 6 months or more postoperatively (p < 0.0001). Mean satisfaction was excellent (3.0 at both 1-month and ≥6-month follow-up; p = 0.46). Cephalometric values were significantly more feminine after surgery. Gender appearance was feminine to very feminine (1.83 ± 0.96) and general aesthetics were good (6.09 ± 2.01) but different from those of cisgender women controls (1.25 ± 0.49 and 7.63 ± 1.82, respectively; p < 0.001 for each). CONCLUSION: Facial feminization achieved improved quality of life, feminized cephalometries, feminine gender appearance, good overall aesthetics, and high satisfaction that were present at 1 month and stable at more than 6 months. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Management of Finger Joint Dislocation and Fracture-Dislocations in Athletes.

Although finger joint dislocations are generally thought of as benign by many athletes and assumed to be a sprain, these injuries represent a spectrum that includes disabling fracture-dislocations. Failure to recognize certain dislocations or fracture-dislocations may result in permanent deformity and loss of motion. Simple dislocations are frequently amenable to early return to play with protection; however, more complex injuries may require specialized splinting or surgery. Delay in diagnosis of unstable proximal interphalangeal fracture-dislocations may require reconstruction or fusion. Early diagnosis and appropriate treatment are essential to ensure optimal functional results.

Postoperative Management and Rehabilitation of the Replanted or Revascularized Digit.

Postoperative care of amputated digits begins before replantation. Detailed informed consent should be obtained and completion amputation discussed if revascularization is not ultimately successful. Complications and failure of the replanted digit should also be addressed. Postoperative pharmacologic treatment should consist of aspirin, at minimum. Complications, such as venous congestion or occlusion, and arterial thrombosis, should be dealt with expediently. Digital motion rehabilitation should start after 5 to 7 days of digital viability and splinting of the affected digit. Early protective motion protocol is implemented to maintain digital motion with emphasis on tendon glide and joint motion.

Strategies for Reconstruction of the Plantar Surface of the Foot: A Systematic Review of the Literature.

BACKGROUND: Reconstruction of the plantar surface of the foot is challenging because of its distinctive anatomy and microarchitecture. Unfortunately, no single coverage option meets the needs of all patients and defects. A comprehensive literature review is presented to better define available reconstructive options for resurfacing the plantar foot. METHODS: A systematic literature search was performed to identify articles relating to reconstruction of the plantar skin and soft tissue. The PubMed, Embase, and Scopus databases were queried for published articles. After the exclusion of duplicate records, 1624 articles were available for review. A total of 280 unique articles were included for analysis, with a total of 2684 individual reconstructions. RESULTS: Of the articles reviewed, 10 percent described a skin grafting technique, 53 percent described a locoregional flap, 32 percent described free tissue transfer, and 5 percent described multiple reconstructive methods. Isolated heel defects were the most frequently reconstructed subunit of the plantar foot (73 percent). The latissimus dorsi muscle was the most commonly used free flap, whereas the reverse sural artery flap was the most commonly used locoregional flap. Protective sensation was noted in most locoregional and free flap reconstructions, regardless of primary neurotization; however, improved two-point discrimination was noted when neurofasciocutaneous flaps were used. Complication rates varied widely, although rates of flap loss approached those of flaps performed at other anatomical sites. CONCLUSIONS: Numerous methods exist for reconstructing the plantar surface. Proper flap selection should be determined by the size of the defect, the availability of donor tissue, and the surgeon's experience and comfort with the reconstructive technique.