Clearing the Smoke: The Evidence behind Risk of Electrocautery Smoke and Mitigation Strategies.

Background: Electrocautery has been a useful, fundamental instrument utilized for surgical procedures since its implementation in the 1920s. However, concerns exist regarding the health hazards of the by-product smoke associated with the use of electrocautery. Methods: A comprehensive review of articles on the composition, mitigation, and effects of smoke was conducted using the PubMed search engine and excluding articles that did not meet the predetermined inclusion criteria. From January 1963 to December 2021, a total of 264 articles resulted, and a total of 69 articles were included in this narrative review. Results: Surgical smoke contains volatile organic compounds, polycyclic aromatic compounds, viral particles, and ultrafine particles. There has been some evidence of mutagenicity to bacterial cells during animal in vivo studies, and one human survey study has shown similar mutagenic effects. We also discuss additional hemostatic techniques that can be used, including the use of hemostatic and antithrombolytic agents, epinephrine infiltration, and the use of tourniquet when appropriate. Conclusions: Further studies should be conducted regarding human effects, but until the data are available, we recommend precautionary measures and actions to protect operating room staff from cautery smoke exposure.

Review of Statutory Obligations for Reporting Ballistic Injuries.

Traumatic ballistic injury is an unfortunate and commonly encountered problem seen by surgeons. An estimated 85,694 nonfatal ballistic injuries occur annually, and in 2020 there were 45,222 firearm-related deaths in the United States. Surgeons of all subspecialties may provide necessary care. Acute care injuries are generally reported to authorities immediately; however, delayed presentation of ballistic injuries may go unreported despite regulations to do so. We present a case of a delayed ballistic injury and a comparative review of individual states' reporting requirements to highlight statutory obligations and penalties as an educational reference for surgeons treating ballistic injuries. Methods: Google and PubMed searches were performed utilizing keywords "ballistic," "gunshot," "physician," and "reporting" as terms. Inclusion criteria included the English language, official state statute sites, legal and scientific articles, and websites. Exclusion criteria included nongovernmental sites and information sources. Data collected were analyzed to include statute numbers, time to report, infraction consequences, and monetary fines. The resultant data are reported by state and region. Results: All but two state jurisdictions mandate healthcare providers to report knowledge and/or treatment of ballistic injuries, regardless of the timeline of injury. Violations of mandatory reporting may lead to fines or imprisonment, depending on the specific state. The timeline for reporting, fines, and subsequent legal action varies by state and region. Conclusions: Requirements for reporting injuries exist in 48 of 50 states. The treating physician/surgeon should thoughtfully question patients with a chronic ballistic injury history and provide reports to local law enforcement.

Biomechanics of an Articulated Screw in Acute Scapholunate Ligament Disruption.

Background An injury to the scapholunate interosseous ligament (SLIL) leads to instability in the scapholunate joint. Temporary fixation is used to protect the ligament during reconstruction or healing of the repair. Rigid screw fixation-by blocking relative physiological motion between the scaphoid and lunate-can lead to screw loosening, pullout, and fracture. Purpose This study aims to evaluate changes in scaphoid and lunate kinematics following SLIL injury and the effectiveness of an articulating screw at restoring preinjury motion. Materials and Methods The kinematics of the scaphoid and lunate were measured in 10 cadaver wrists through three motions driven by a motion simulator. The specimens were tested intact, immediately following SLIL injury, after subsequent cycling, and after fixation with a screw. Results Significant changes in scaphoid and lunate motion occurred following SLIL injury. Postinjury cycling increased motion changes in flexion-extension and radial-ulnar deviation. The motion was not significantly different from the intact scapholunate joint after placement of the articulating screw. Conclusion In agreement with other studies, sectioning of the SLIL led to significant kinematic changes of the scaphoid and lunate in all motions tested. Compared with intact scapholunate joint, no significant difference in kinematics was found after placement of the screw indicating a correction of some of the changes produced by SLIL transection. These findings suggest that the articulating screw may be effective for protecting a SLIL repair while allowing the physiological rotation to occur between the scaphoid and lunate. Clinical Relevance A less rigid construct, such as the articulating screw, may allow earlier wrist rehabilitation with less screw pullout or failure.

A Mechanical Evaluation of Zone II Flexor Tendon Repair Using a Knotless Barbed Suture Versus a Traditional Braided Suture.

PURPOSE: To determine repair site bulk, gliding resistance, work of flexion, and 1-mm gap formation force in zone II flexor tendon lacerations repaired with knotless barbed or traditional braided suture. METHODS: Transverse zone II lacerations of the flexor digitorum profundus (FDP) tendon were created in 36 digits from 6 matched human cadaveric pairs. Repair was performed with 2-0 barbed suture (n = 18) or 3-0 polyethylene braided suture (n = 18). Pre- and postrepair cross-sectional area was measured followed by quantification of gliding resistance and work of flexion during cyclic flexion-extension loading at 10 mm/min. Thereafter, the repaired tendons were loaded to failure. The force at 1 mm of gap formation was recorded. RESULTS: Repaired FDP tendon cross-sectional area increased significantly from intact, with no difference noted between suture types. Gliding resistance and work of flexion were significantly higher for both suture repairs; however, we identified no significant differences in either nondestructive biomechanical parameters between repair types. Average 1-mm gap formation force with the knotless barbed suture (52 N) was greater than that of the traditional braided suture (43 N). CONCLUSIONS: We identified no significant advantage in using knotless barbed suture for zone II FDP repair in our primary, nondestructive mechanical outcomes in this in vitro study. CLINICAL RELEVANCE: In vivo studies may be warranted to determine if one suture method has an advantage with respect to the parameters tested at 4, 6, and 12 plus weeks postrepair and the degree of adhesion formation. The combined laboratory and clinical data, in additional to cost considerations, may better define the role of barbed knotless suture for zone II flexor tendon repair.

Implant-associated anaplastic large cell lymphoma: beyond breast prostheses.

OBJECTIVE: Anaplastic large cell lymphoma (ALCL) is a rare form of non-Hodgkin T-cell lymphoma potentially associated with silicone-shelled breast implants. The low incidence of ALCL has prevented establishment of causality. Many implantable devices are constructed with biomaterials similar to those used in breast prostheses. The purpose of this paper is to identify reports of ALCL in association with other types of implantable devices. METHODS: A literature review was conducted using PubMed to identify reports of non-Hodgkin lymphoma in association with various implantable devices. RESULTS: One case of ALCL was identified in association with a stainless steel internal fixation plate. Diffuse large B-cell lymphoma was widely reported in association with various implantable biomaterials and chronic inflammation. CONCLUSION: The neoplastic response associated with breast prostheses appears substantively different from other implantable devices. Physicians caring for patients with silicone elastomer-containing implants should have increased suspicion for implant-associated ALCL and report all pertinent cases in the literature.

Successful use of ultrasound-guided compression for a princeps pollicis artery pseudoaneurysm: case report.

A 73-year-old man receiving heparin developed a large hematoma in the first web after a routine blood draw. Color Doppler ultrasound demonstrated a pseudoaneurysm of the princeps pollicis artery. Ultrasound-guided compression resulted in successful thrombosis of the pseudoaneurysm.

Comparative evaluation of silver-containing antimicrobial dressings on in vitro and in vivo processes of wound healing.

OBJECTIVES: To compare the in vitro and in vivo effects of silver products on wound healing. METHODS: Eight silver products were compared to determine: fibroblast function using fibroblast-populated collagen lattices (FPCLs), fibroblast viability using the Trypan Blue exclusion test, and fibroblast mitochondrial activity using the MTT [yellow tetrazolium salt; 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay. In vivo effects of 9 silver products were evaluated utilizing a rat model of contaminated wounds. Serial quantitative bacteriology was performed on tissue biopsies over a 10-day period and serial wound areas were obtained over 12 days. RESULTS: Fibroblast cytotoxicity occurred for all of the silver products evaluated. Remaining viable fibroblasts were insufficient to allow FPCL contraction. Mitochondrial activity of the fibroblasts allowed a separation of the various silver compounds. Actisorb Silver and Silvercel had the greatest viable fibroblast activity, but less than the control. Despite in vitro cytotoxicity, all of the silver products except Contreet Foam and Acticoat Moisture Control accelerated wound healing. CONCLUSIONS: Silver-containing dressings appeared to benefit healing of the wounds. Just as in vitro bacterial analyses do not fully predict the effect of an antimicrobial in the in vivo setting, in vitro cytotoxicity tests do not fully predict the effect of an agent on wound healing trajectories. Because of the varied antimicrobial and wound healing responses among products, a careful consideration of the particular effects of individual silver-containing dressings or drugs is warranted.

Sequelae of fat grafting postmastectomy: an algorithm for management of fat necrosis.

OBJECTIVE: Fat grafting is used to improve the reconstructed breast. Local recurrences following mastectomy present as palpable subcutaneous nodules; fat necrosis/oil cysts, a sequelae of fat grafting, also present as subcutaneous nodules. Our objective was to examine the frequency and factors associated with fat necrosis in the postmastectomy reconstructed breast and propose an algorithm for management. METHODS: A retrospective review of a breast reconstruction database was conducted to identify patients treated with fat grafting. Clinical-pathologic data at cancer presentation, volume of fat injection, occurrence of subcutaneous nodules, and outcome were collected. Statistical analysis was performed to compare the development of a palpable mass with continuous and categorical variables. RESULTS: A total of 278 patients who had fat grafting with breast reconstruction were identified. Sixty-four patients (23%) developed a palpable mass at a median time of 10 months (range: 2-39). Seventeen (6%) subsequently underwent needle or excisional biopsy (16 fat necrosis/oil cysts; 1 recurrent carcinoma). The recurrent carcinoma identified did not correlate with the location of fat grafting. No clinical-pathologic (age, body mass index, stage, smoking, radiation) or technical variables (fat/tumescent volume) were found to predict development of fat necrosis. CONCLUSIONS: Fat grafting improves cosmesis but has a significant risk of fat necrosis. Awareness of fat injection location, incidence, time to development, and characteristic examination may decrease anxiety and need for imaging/biopsy.

Further information from a sonometric study of the normal tricuspid valve annulus in sheep: geometric changes during the cardiac cycle.

BACKGROUND AND AIM OF THE STUDY: In a previous sono-metric study, changes were described that occurred in the normal tricuspid valve during the cardiac cycle. However, the wealth of data available suggested the need for reporting further findings that should contribute to a better understanding of the dynamics of the tricuspid valve. METHODS: Thirteen sonomicrometry transducers were placed in the hearts of each of seven sheep. Six transducers were placed in the tricuspid annulus (TA), at the base of each leaflet, and at each commissure; three at the tips of the papillary muscles (PMs); three in the free edges of the leaflets; and one transducer was placed at the apex. Distances between transducers, pulmonary and right ventricular pressures, and pulmonary flow were recorded simultaneously. RESULTS: The TA area underwent two major contractions and expansions during the cardiac cycle, reaching its maximum during isovolumic relaxation and its minimum in diastole. The TA height-to-width ratio changed from 8.4 +/- 1.9% to 15.3 +/- 4.2%. The leaflets began to open before end-systole. By the end of isovolumic relaxation, the leaflets had completed 54.1 +/- 13.4% of their opening. The PM and TA planes were not parallel, but were offset by 11.5 +/- 1.9 degrees to 17.8 +/- 2.1 degrees. The PM rotated 6.9 +/- 0.9 degrees with respect to the TA, with 3.1 +/- 1.1 degrees of the rotation occurring during ejection. CONCLUSION: The tricuspid valve is not a passive structure but rather forms a dynamic part of the right ventricle. Its orifice area changes not only due to the contraction and expansion of its perimeter but also to changes in its saddle shape. Leaflet opening and closure is not simply a response to pressure. The PMs rotate in relation to the TA. These data should impact upon the diagnosis and surgery of functional tricuspid regurgitation.

Sonometric study of the normal tricuspid valve annulus in sheep.

BACKGROUND AND AIM OF THE STUDY: Mitral valve dynamic changes during the cardiac cycle have been previously studied in sheep using sonomicrometry. The study aim was to analyze geometric changes of the normal tricuspid annulus in sheep using a similar methodology. This is most likely the first tricuspid valve study using high temporal resolution (200 Hz = 200 data points per second). METHODS: Thirteen crystals were implanted in seven sheep along the annulus (n = 6), at the tips of papillary muscles (n = 3), at the free edge of the leaflets (n = 3), and at the apex of the left ventricle (n = 1). Recordings (10 s) of crystal distances were used to create a three-dimensional (3D) coordinate system based on the least-squares plane of the annulus, and maximum and minimum values were calculated for length, area, and position in xyz coordinates. RESULTS: During the cardiac cycle, the tricuspid annulus area expanded 28.6 +/- 3.6% with similar maximum expansions of each segment along the annulus: septal (10.4 +/- 1.2%), anterior (13.0 +/- 1.5%), and posterior (14.0 +/- 1.6%). The annulus was saddle-shaped, with a circumferential expansion from elliptical at minimum area to more circular at maximum area. The time delay to maximum leaflet area and maximum papillary area occurred 83 +/- 13 ms and 279 +/- 30 ms respectively after maximum annulus area. CONCLUSION: The tricuspid valve undergoes continual and complex geometric changes during the cardiac cycle. In addition, the annulus expands significantly due to similar increases in length of the septal and free wall segments. The annulus is not in a single plane, but is saddle-shaped. The expansion and contraction of the tricuspid valve complex is stepwise, and sequential from base to apex.