Career Outcomes of Nondesignated Preliminary Surgery Residents: A Systematic Review and Meta-Analysis.

OBJECTIVE: Nondesignated preliminary surgery (NDPS) residency offers postgraduate medical education with no guarantee of a subsequent categorical position. Some literature exists detailing the career outcomes of these residents, but these results are complicated by the limited scale of these studies. The purpose of this systematic review and meta-analysis is to summarize the career outcomes of these residents from the existing literature. METHODS: The PubMed, Scopus, Cochrane, CINAHL, and PsycINFO databases were queried from inception for studies reporting the career outcomes of NDPS residents. Data were collected and extracted by 2 independent reviewers in accordance with PRISMA guidelines. The primary outcome of this study is the proportion of NDPS residents obtaining a categorical general surgery position. Secondary outcomes include the percentages of residents obtaining surgical subspecialty positions, obtaining nonsurgical specialty positions, and leaving graduate medical education. RESULTS: Overall, 13 studies reporting NDPS residents (n = 2606) were identified. The overall pooled estimate for obtaining a categorical general surgery position after NDPS residency was 37.1% (95% CI, 31.3%-43.2%), with significant heterogeneity (I2 = 81.8%; p < 0.001). Residents in the second postgraduate year were significantly more likely than those in the first year to obtain a general surgery position (50.6% vs 29.0%, respectively; p < 0.001). Residents subsequently training in a surgical subspecialty (13.3%) largely entered orthopedics (3.6%), urology (2.1%), and obstetrics and gynecology (1.6%). For residents entering nonsurgical training (32.1%), a majority entered anesthesiology (11.7%), internal medicine (3.8%), and radiology (3.8%). CONCLUSIONS: Although NDPS residents have heterogenous career outcomes, they largely obtain categorical positions in general surgery and surgical subspecialties.

Sacroiliac Joint Fusion-A Shift Toward Variant Anatomy and Clinical Implications.

OBJECTIVE: To investigate impact of patient factors and sacroiliac joint (SIJ) anatomical structure on SIJ fusion outcomes. METHODS: This single-center, retrospective, observational study evaluated patients diagnosed with SIJ dysfunction refractory to conservative measures who had available preoperative imaging of the sacrum and underwent SIJ fusion surgery. The impact of patient sociodemographics on pain improvement was assessed by Mann-Whitney U test. Differences in patient sociodemographics and outcome information between anatomical subtypes were assessed with χ2 and Kruskal-Wallis tests. χ2 test was used to compare joint anatomy distribution between studies analyzing SIJ variations. RESULTS: We included 77 total joints that underwent instrumentation. There were significant differences between the anatomical subtypes with female sex having significantly higher rates of non-normal joint anatomy. Younger age was significantly more common in bipartite/dysmorphic anatomy (53.9 years) than normal anatomy (70 years) (P < 0.05). There was a trend toward better outcomes in bipartite/dysmorphic and accessory variants, while semicircular defect and crescent variants trended toward worse outcomes. Nonnormal anatomy was significantly more frequent in our population than previous reports on nonpathological SIJ. CONCLUSIONS: A pathological SIJ has a significantly higher prevalence of variant joint anatomy. There appears to be a trend toward differences in surgical outcomes based on SIJ anatomy. Future research with larger sample sizes is necessary to confirm these differences.

3-Dimensional Exoscope for Far Lateral Approach to Pontomedullary Cavernous Malformation.

Brainstem cavernous malformations account for 15%-18% of all central nervous system cavernomas and are histologically characterized by thin-walled, low-pressure capillaries, classically without intervening brain tissue.1,2 Cavernomas may be sporadic, typically characterized by a single lesion, or inherited. The inherited form is most often autosomal dominant with incomplete penetrance and variable expression. Multiple cavernomas are associated with the familial form; although this is not always the case, genetic workup should be pursued.3,4 Clinical presentation typically includes focal neurologic deficit related to hemorrhage location, seizures, and rarely obstructive hydrocephalus.1,2 Indications for surgical management include severe or progressive neurologic dysfunction, lesion size ≥2 cm, recurring hemorrhages, and/or significant mass effect.5 Microsurgical resection of a cavernoma is associated with an overall 28% complication rate and perioperative neurologic morbidity upwards of 45% according to some series. Long-term surgical outcomes at 12 months are more reassuring: 84% reported their condition to have improved or remained the same, and the long-term morbidity rate is 14%.1,6 The location of the lesion dictates the approaches available-cavernomas in the pons or medulla are commonly approached via a retrosigmoid or retrolabyrinthine approach, while more ventral pathologies in this region necessitate a far lateral approach.1,5,7,8 In Videos 1 and 2, we describe our experience with an exoscope-assisted far lateral approach to a pontomedullary cavernoma in a 10-year-old male presenting with numerous cavernomas and confirmed gene mutation. We demonstrate the exoscope's unparalleled visualization of the anterolateral brainstem, with nominal condylar drilling. The patient and his parents consented to the procedure and publication.

Prevalence of Visible Subdural Spaces in Benign Enlargement of Subarachnoid Spaces in Infancy: A Retrospective Analysis Utilizing Magnetic Resonance Imaging.

OBJECTIVE: Benign Enlargement of the Subarachnoid Spaces in Infancy (BESSI) is a common finding during workup for progressive macrocephaly. BESSI has been associated with slightly higher prevalence of subdural (SD) spaces and a risk for developing subdural hematoma. This study utilizes fast brain magnetic resonance imaging (MRI) to investigate the prevalence of visible SD spaces in BESSI. METHODS: A retrospective review was performed for all pediatric patients who underwent brain MRI for macrocephaly. Patients with a diagnosis of BESSI were included in the study. A total of 109 patients met the inclusion criteria. Patient demographics were collected, and images were reviewed for size of subarachnoid, visible SD spaces, and ventricle size. Descriptive and inferential statistics were performed. RESULTS: The average age was 8 ± 4.6 months, 64 (59%) were male, and 55 patients had no previous medical history (50%). Sixty-seven percent of all patients were identified to have visible SD spaces. Eleven patients had confirmed SD hematomas; 1 patient was deemed to have abusive head trauma. Visible SD spaces were associated with younger age (6.9 months). Thirty-one patients with visible SD spaces had follow-up MRI, with complete resolution by 33 months. CONCLUSIONS: BESSI is a self-limiting pathology that has been associated with visible SD spaces and potential risk for SD hemorrhages. We report a high prevalence of visible SD spaces within BESSI through utilization of fast brain MRI. These spaces may contribute to the higher rate of incidental subdural hematoma in this population.

Identification of Neuronal Lineages in the Drosophila Peripheral Nervous System with a "Digital" Multi-spectral Lineage Tracing System.

Elucidating cell lineages provides crucial understanding of development. Recently developed sequencing-based techniques enhance the scale of lineage tracing but eliminate the spatial information offered by conventional approaches. Multi-spectral labeling techniques, such as Brainbow, have the potential to identify lineage-related cells in situ. Here, we report nuclear Bitbow (nBitbow), a "digital" version of Brainbow that greatly expands the color diversity for scoring cells, and a suite of statistical methods for quantifying the lineage relationship of any two cells. Applying these tools to the Drosophila peripheral nervous system (PNS), we determined lineage relationship between all neuronal pairs. This study demonstrates nBitbow as an efficient tool for in situ lineage mapping, and the complete lineage relationship among larval PNS neurons opens new possibilities for studying how neurons gain specific features and circuit connectivity.

Outcome of Dupuytren Contractures After Collagenase Clostridium Histolyticum Injection: A Single-institution Experience.

BACKGROUND: Collagenase clostridium histolyticum (CCH) injection is an alternative to surgery for patients with Dupuytren disease (DD) of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The success of surgical and nonsurgical treatment modalities for DD is reported to vary widely between 25% and 80% (J Bone Joint Surg Am. 1985;67:1439-1443; Plast Reconstr Surg. 2007;120:44e-54e; J Bone Joint Surg Am. 2007;89:189-198; J Hand Surg Am. 2011:36:936-942; J Hand Surg Am. 1990;15:755-761; J Hand Surg Br. 1996;21:797-800; J Bone Joint Surg Br. 2000;82:90-94; Plast Reconstr Surg. 2005;115:802-810; Ann Plast Surg. 2006;57:13-17). This study presents the outcomes of patients with DD contractures treated with CCH injections at a single institution. METHODS: An institutional review board-approved retrospective study was conducted of patients with DD of the hand treated with CCH injections in a single institution from February 2010 to April 2015. All patients received the recommended dose of 0.58 mg of CCH and returned for joint manipulation the following day. Data for follow-up at 7 and 30 days postoperatively and up to 5 years for patients who returned seeking further therapy for recurrent symptoms were reviewed. RESULTS: One hundred thirteen patients with a total of 146 affected joints (72 MCP; 74 PIP) were treated with CCH injections (95 males; 18 females; age, 40-92 y). Successful CCH therapy occurred in 75% of injected joints (109/146 joints; 59 MCP; 50 PIP), as defined by less than 5 degrees of contracture after treatment. Twenty-three percent of treated joints had partial correction (34/146 joints; 13 MCP; 21 PIP), as defined by between 5 and 30 degrees of residual contracture after treatment. Three patients (2%) had a failure of treatment, as defined by unchanged or worsened contracture from pretreatment baseline measurements. Fifteen patients (13%) returned to the clinic seeking additional therapy for recurrent joint contracture symptoms in 17 joints over a span of 1.5 months to 4 years after initial successful or partially successful treatment (17/143, 12%; 5 MCP; 12 PIP). Recurrence was defined as patients who sought treatment for a return of symptoms or greater than 20 degrees contracture in the setting of a palpable cord after initial full or partial contracture correction. DISCUSSIONS: Our 5-year outcome of CCH injections for DD contractures revealed full correction in 75% and partial correction in 23% of treated joints, with failure of treatment seen in only 2% of patients. Thirteen percent of the patients returned for additional treatment because of symptoms resulting from contracture recurrence in 12% of initially corrected or partially corrected joints. These positive outcomes are comparable with current surgical treatment modalities (J Hand Surg Am. 1990;15:755-761; J Bone Joint Surg Am. 1962;44B:602-613; J Clin Epidemiol. 2000;53:291-296). The use of CCH injections is an important nonsurgical treatment alternative for DD contractures of the MCP and PIP joints.

Hand and forearm reconstruction after skin cancer ablation.

Skin cancer is common on the dorsum of the hand and forearm. The reconstructive challenges in this area are significant, and the options are myriad. Thus, the surgeon who takes on this challenge must know the various options. These options include the entire reconstructive ladder from direct closure all the way through to composite-free tissue transfer. Nail bed reconstruction should be mastered. In addition, the surgeon should be comfortable with all the reliable flaps, including the kite flap, the cross-finger flap, the reverse cross-finger flap, the rotation-advancement flaps, transposition flaps, and the radial forearm flap.

Bilateral lipoma arborescens of the bicipitoradial bursa.

A 37-year-old military mechanic presented to our institution with a chronic history of a slowly enlarging left elbow antecubital fossa mass. There was no history of other chronic illness or trauma. Magnetic resonance imaging (MRI) and excisional biopsy revealed fatty villi and synovial inflammation within the left bicipitoradial bursa, consistent with lipoma arborescens. Four years later the patient presented with a 6-month history of swelling at the antecubital fossa of the opposite elbow. Diagnostic computed tomography and MRI examinations were performed. The surgical and pathologic findings confirmed the imaging diagnosis of lipoma arborescens at the right bicipitoradial bursa.