What a Ratchet! A Gripping Case Report of an Entrapped Finger with an Unyielding Wrench.

Finger entrapment with rings or ring-like objects is an uncommon possible hand emergency. In cases in which noncutting removal is ineffective, ring cutters or dental drills with carbide or diamond burs have been successfully used. However, objects composed of hard metallic alloys, such as lug nuts or wrenches, are often resistant to such equipment. In these instances, larger diameter metal cutting burrs or rasps may be more advantageous. Due to their increased size and cutting power, these tools are better suited to handle the toughness of hard metals. In this case report, we present the effective and efficient removal of a stainless steel wrench from an entrapped digit using a helicoidal rasp. Availability of this instrument within orthopedic departments may prevent the delays often described in the treatment of finger entrapment when traditional cutting equipment fails.

Prepectoral Direct-to-Implant versus Staged Tissue Expander Breast Reconstruction: A Comparison of Complications.

BACKGROUND: Direct-to-implant (DTI) reconstruction has multiple advantages over a staged tissue expander (TE) approach. However, its use may be limited by concerns of increased complications. This study is the largest series to date comparing postoperative outcomes for DTI versus TE reconstruction in the prepectoral plane. METHODS: The authors retrospectively reviewed 348 patients that received 536 total immediate, prepectoral implant-based breast reconstructions between January 2018 and December 2021. The authors compared the presence of risk factors and the rate of six separate complications between patients that received DTI versus TE reconstruction up to one year after surgery. RESULTS: Of 348 patients, 147 (42%) and 201 (58%) underwent TE and DTI reconstruction (p=0.1813), respectively. Overall infection rate was 16.4% (n=57). DTI patients had a significantly greater incidence of wounds (p<0.0001), including minor (p<0.0011) and major wounds (p<0.0053). Significantly greater mastectomy resection weights were found for DTI patients that experienced any complication (p<0.0076), postoperative wounds (p<0.0001), and major wounds specifically (p<0.0035). Compared to medium thickness, extra-thick acellular dermal matrix (ADM) was associated with significantly increased rates of infection (p<0.0408) and wounds (p<0.0001). CONCLUSIONS: Prepectoral DTI reconstruction in patients with adequate flap perfusion may have comparable complication rates to staged TE reconstruction apart from a higher incidence of postoperative wounds. Greater mastectomy resection weights and thickness of ADM may specifically contribute to infectious and wound-healing complications. Prepectoral DTI reconstruction is encouraged in the patients with adequate flap perfusion and moderate to low mastectomy resection weights that desire comparable or smaller implant volumes.

Pronator Quadratus Muscle Flap for Prevention of Flexor Tendon Rupture after Distal Radius Volar Plating.

Background: Flexor tendon rupture is a serious but rare complication that can occur after volar plating of distal radius fractures. This study aims to introduce a novel surgical technique that uses a pronator quadratus (PQ) muscle flap transposition to protect the flexor tendons from rupture or irritation and evaluate its outcomes. Methods: A retrospective review was conducted on 204 patients with unstable distal radius fractures who underwent a standard volar flexor carpi radialis approach with extended release of the PQ muscle during exposure. A PQ muscle flap was harvested and transposed over the distal edge of the plate after open reduction and internal fixation of the distal radius. Postoperatively, patients were evaluated for flexor tendon irritation and rupture. Patients who had this injury before the use of the PQ flap were compared with the patients who received the PQ flap. Results: Of the 204 patients, 119 received the PQ flap, and 85 did not. The mean follow-up time was 30.4 months. Among the patients who did not receive the PQ flap, five (5.9%) required plate removal or conservative treatment for tendon irritation or rupture. In contrast, only one patient (0.8%) who received the PQ flap required plate removal for flexor tendon irritation. Conclusions: The PQ muscle flap is a quick and effective surgical technique that reduces the risk of flexor tendon rupture or irritation during distal radius fracture fixation. The PQ muscle flap acts as a buffer between the plate and tendon and is more effective than not transposing the muscle.

Comparison of Collagen and Human Amniotic Membrane Nerve Wraps and Conduits for Peripheral Nerve Repair in Preclinical Models: A Systematic Review of the Literature.

BACKGROUND: Collagen and human amniotic membrane (hAM) are Food and Drug Administration (FDA)-approved biomaterials that can be used as nerve wraps or conduits for repair of peripheral nerve injuries. Both biomaterials have been shown to reduce scarring and fibrosis of injured peripheral nerves. However, comparative advantages and disadvantages have not been definitively shown in the literature. The purpose of this systematic review is to comprehensively evaluate the literature regarding the roles of hAM and collagen nerve wraps and conduits on peripheral nerve regeneration in preclinical models. METHODS: The MEDLINE database was queried using the PubMed search engine on July 7, 2019, with the following search strategy: ("amniotic membrane" OR "amnion") OR ("collagen conduit" OR "nerve wrap")] AND "nerve." All resulting articles were screened by two independent reviewers. Nerve type, lesion type/injury model, repair type, treatment, and outcomes were assessed. RESULTS: Two hundred and fifty-eight articles were identified, and 44 studies remained after application of inclusion and exclusion criteria. Seventeen studies utilized hAM, whereas 27 studies utilized collagen wraps or conduits. Twenty-three (85%) of the collagen studies utilized conduits, and four (15%) utilized wraps. Six (35%) of the hAM studies utilized conduits and 11 (65%) utilized wraps. Two (9%) collagen studies involving a conduit and one (25%) involving a wrap demonstrated at least one significant improvement in outcomes compared with a control. While none of the hAM conduit studies showed significant improvements, eight (73%) of the studies investigating hAM wraps showed at least one significant improvement in outcomes. CONCLUSION: The majority of studies reported positive outcomes, indicating that collagen and hAM nerve wraps and conduits both have the potential to enhance peripheral nerve regeneration. However, relatively few studies reported significant findings, except for studies evaluating hAM wraps. Preclinical models may help guide clinical practice regarding applications of these biomaterials in peripheral nerve repair.

A characterization of home maintenance equipment-related hand and lower arm injuries.

Background: Thousands of Americans sustain injuries from various household appliances each year, though injury patterns have not been well characterized. We thus sought to determine the incidence, characteristics, and trends of household appliance-related hand injuries over the past decade. Methods: The National Electronic Injury Surveillance System database (NEISS) was queried from 2010 through 2019. Our analysis grouped patients into 10-year age groups. We defined types of appliances and injuries Chi-square tests were used to compare the most common injury mechanisms by age group. Results: Between 2010 and 2019, 30,336 total cases of home workshop equipment-related upper extremity injuries were recorded; 2,574 (8.48%) of these affected females, compared to 27,762 (91.52%) of the cases affecting males. Across all age groups, males were between 6 and 13 more times likely to be injured than females (p < 0.001). Between 2010 and 2019, we recorded a decline in total injuries from 168,795 to 147,584, with a Pearson correlation coefficient of -0.68 (p = 0.031). The appliances most likely to injure those in their 10s through 40s were mechanical tools such as screwdrivers. Meanwhile, those in their 50s through 70s were most likely to be injured by saws. Both amputations and avulsions were found to significantly increase with age (p = 0.038, p = 0.027, respectively). Most injuries result from manual tools and saws. Discussion: Males are significantly more likely to incur injuries than females from maintenance equipment, and risk of avulsions and amputations increase significantly with age. This aligns with previous research which also suggested that older saws were most likely to injure older individuals; namely, following new regulations on saws, older adults were more likely to be affected. This is especially worrisome in light of recent research showing that older adults with amputations are less likely to be offered replantations. Overall, these results can continue to guide and optimize community interventions on an epidemiological basis.

Reconstruction of the Scrotum With Bilateral Gracilis Muscle Rotational Flaps in a Patient With Acute Myeloid Leukemia Complicated by Fournier's Gangrene.

We describe the case of a 43-year-old male diagnosed with acute myeloid leukemia complicated by Fournier's gangrene. Multiple debridements led to the complete effacement of the scrotum, with 360 degrees of exposed testes and a narrow base of suspension. It was decided to reconstruct the scrotum using bilateral gracilis muscle rotational flaps, followed by split-thickness skin grafting from the thigh. The gracilis muscle as a donor flap allowed for the protection and support of the testes and suspensory tissue while achieving an aesthetically pleasing result that resembled the normal scrotum. We hope providers will consider this reconstructive method in future patients who present with similar extensive effacement of the scrotal tissue.

Comparison of human amniotic membrane and collagen nerve wraps around sciatic nerve reverse autografts in a rat model.

Human amniotic membrane (hAM) and collagen nerve wraps are biomaterials that have been investigated as therapies for improving outcomes of peripheral nerve regeneration; however, their efficacy has not been compared. The purpose of this study is to compare the efficacy of collagen and human amniotic membrane nerve wraps in a rodent sciatic nerve reverse autograft model. Lewis rats (n = 29) underwent sciatic nerve injury and repair in which a 10-mm gap was bridged with reverse autograft combined with either no nerve wrap (control), collagen nerve wrap or hAM nerve wrap. Behavioral analyses were performed at baseline and 4, 8 and 12 weeks. Electrophysiological studies were conducted at 8, 10 and 12 weeks. Additional outcomes assessed included gastrocnemius muscle weights, nerve adhesions, axonal regeneration and scarring at 12 weeks. Application of both collagen and hAM nerve wraps resulted in improvement of functional and histologic outcomes when compared with controls, with a greater magnitude of improvement for the experimental group treated with hAM nerve wraps. hAM-treated animals had significantly higher numbers of axons compared to control animals (p < 0.05) and significantly less perineural fibrosis than both control and collagen treated nerves (p < 0.05). The ratio of experimental to control gastrocnemius weights was significantly greater in hAM compared to control samples (p < 0.05). We conclude that hAM nerve wraps are a promising biomaterial that is effective for improving outcomes of peripheral nerve regeneration, resulting in superior nerve regeneration and functional recovery compared to collagen nerve wraps and controls.

Recurrent and persistent carpal tunnel syndrome: "Triple-therapy approach".

BACKGROUND: Various procedures have been described for patients undergoing a revision carpal tunnel release. These can include repeat open decompression with external or internal neurolysis, tenosynovectomy, endoscopic release, various flap techniques, saphenous vein wrapping and use of prosthetic implants. This study reports a case series of 30 consecutive patients who underwent revision carpal tunnel release at single institution from 2012 to 2018. Our surgical plan in all the patients involved a combination of these three techniques (triple therapy approach): neurolysis (external or internal) and tenosynovectomy, collagen matrix conduit wrap (NeuraWrap; Integra LifeSciences or Axoguard Nerve Protector, AxoGen Inc), and hypothenar fat flap. MATERIALS AND METHODS: A total of 30 patient records were identified. The index surgery was performed by a variety of surgeons at varied private institutions as well as the VA hospital. However, all of the revision interventions in this series were performed by the senior author (Z.J.P.). Demographic data (age, sex, hand dominance, comorbidities, alcohol, and smoking history) were collected. Preoperative and postoperative symptoms were recorded for all patients, including: subjective outcomes, need for additional surgery and complications. Mean VAS preoperatively and postoperatively were compared using a paired t-test. All statistical analyses were performed with SPSS 20 (IBM, Chicago, IL). RESULTS: Patient reported measures of resolution of symptoms and VAS scores documented at 3 months. Of the 30 patients who underwent surgery for persistent or recurrent carpal tunnel syndrome, symptoms resolved completely in 25 patients. 2 patients were lost to follow up. 3 patients showed no improvement. The mean preoperative VAS score was 4.37 and declined to 1.23 after surgery (P < .0001). CONCLUSION: Our study demonstrates that a combination of neurolysis and tenosynovectomy along with a nerve wrap and hypothenar fat flap should be considered in patients presenting with recurrent or persistent carpal tunnel syndrome.

Neisseria elongata osteomyelitis: Literature review and case report in a 63-year-old male presenting with progressive right-handed redness, swelling and pain.

INTRODUCTION: Neisseria elongata, a gram-negative rod, has been identified in 23 cases of pathogenesis in the literature, of which only 2 were osteomyelitis. Here we report the third known case of isolated N. elongata cultures in a digital osteomyelitis. PRESENTATION OF CASE: A 63-year-old male with peripheral vascular disease and lower extremity wounds presented to his vascular surgeon with right-handed redness and pain requiring urgent surgical intervention. Irrigation, debridement, and partial thumb amputation were performed, followed by treatment with a 6-week course of antibiotics. DISCUSSION: N. elongata is a rare cause of osteomyelitis and unfamiliarity with the causal organism and rod-like morphology may delay diagnosis and treatment. CONCLUSION: Gram-negative coverage should be considered in high-risk populations with cellulitis to prevent progression to fulminant abscesses, suppurative tenosynovitis and osteomyelitis.

Accidental Magnetic Resonance Imaging Activation of Carbon Dioxide Tissue Expanders.

Implant-based reconstruction is the most common form of breast reconstruction following mastectomy. It is most often performed in 2 stages using saline-based tissue expanders, which are then exchanged for permanent implants. Serial expansions are performed by accessing a port in the office, an inconvenient and sometimes painful process. A carbon dioxide tissue expander is a device that provides a needle-free, patient-controlled expansion utilizing a remote-controlled CO2 canister. While a patient-controlled expansion offers convenience, given that the CO2 reservoir holds approximately 1500 mL of gas, the potential for malfunction resulting in an uncontrolled expansion in unique to this device. The authors present a case report of a patient with bilateral pre-pectoral tissue expanders who underwent magnetic resonance imaging, resulting in uncontrolled expansion.

Latissimus Dorsi Flap in Breast Reconstruction: Recent Innovations in the Workhorse Flap.

BACKGROUND: Surgeons employ the latissimus dorsi flap (LDF) for reconstruction of a large variety of breast cancer surgery defects, including quadrantectomy, lumpectomy, modified radical mastectomy, and others. The LDF may be used in delayed or immediate reconstruction, in combination with tissue expanders for a staged reconstruction, with implant-based immediate reconstruction, or alone as an autogenous flap. METHODS: The authors discuss the historical uses and more recent developments in the LDF. More recent advancements, including the "scarless" approach and augmentation with the thoracodorsal artery perforator flap, are discussed. RESULTS: The LDF is a reliable means for soft tissue coverage providing form and function during breast reconstruction with acceptable perioperative and long-term morbidities. CONCLUSIONS: When there is a paucity of tissue, the LDF can provide tissue volume in autologous reconstruction, as well as a reliable vascular pedicle for implant-based reconstruction as in the setting of irradiated tissue.

The Relationship of Bacterial Biofilms and Capsular Contracture in Breast Implants.

Capsular contracture is a common sequelae of implant-based breast augmentation. Despite its prevalence, the etiology of capsular contracture remains controversial. Numerous studies have identified microbial biofilms on various implantable materials, including breast implants. Furthermore, biofilms have been implicated in subclinical infections associated with other surgical implants. In this review, we discuss microbial biofilms as a potential etiology of capsular contracture. The review also outlines the key diagnostic modalities available to identify the possible infectious agents found in biofilm, as well as available preventative and treatment measures.

The Planning and Execution of Surgical Hand Mission Trips in Developing Countries.

An important teaching tool and overall humanitarian good, medical mission trips are a common theme among health care professionals. These trips encompass large potential for education, global health progress, and cultural exposure, but the logistics of planning and execution are just as great and if not given serious consideration can limit success. This article sets out to explain the importance of planning and to provide specifics that are unique to surgical hand mission trips. Establishing trustworthy relationships, adapting to the host nation's limited resources, and preparing the proper surgical procedures for the particular areas' most common surgical needs are all discussed in this article.

Trends in the incidence and treatment of necrotizing soft tissue infections: an analysis of the National Hospital Discharge Survey.

Necrotizing soft tissue infections are a rare but potentially fatal condition of the soft tissues caused by virulent, toxin-producing bacteria. In the United States, there is an estimated annual incidence of 0.04 cases per 1000 annually, but previous estimates of the Centers for Disease Control and Prevention had the incidence at 500 to 1500 cases yearly. Early reports of mortality were variable with rates ranging from 46 to 76% but outcomes have been improving over time. The National Hospital Discharge Survey was analyzed to study current trends in the demographics, incidence, use, and mortality of patients diagnosed with necrotizing soft tissue infections. The authors analyzed the 1999, 2002, and 2007 National Hospital Discharge Survey by using a sampling weighting method. A total of 13,648 cases of necrotizing soft tissue infections were identified in 2007. This represents an increase from 12,153 cases in 2002 and 6612 cases in 1999. In the 9 years from 1999 to 2007 the gross incidence of necrotizing soft tissue infections more than doubled. Hospital stay was essentially unchanged within study years, at 16 days. Mean age increased from approximately 50 years in 1999 to 54 years in 2007. Further, mortality went from 10.45% in 1999 to 9.75% in the 2007 survey. The population-adjusted incidence rate increased 91% in the studied years. Rising use of immunosupression, exponential growth in the incidence of obesity, and type 2 diabetes could be a major contributing factor. The mortality rate is far below the rate in reports published from as early as 20 years ago, and at 9.75% compares with modern case series, but is a more accurate measure of mortality in this condition.

Merkel cell carcinoma of the hand and upper extremity: current trends and outcomes.

Merkel cell carcinomas represent an uncommon yet aggressive skin cancer. We sought to identify changes in incidence and predictors of outcomes and survival of patients with Merkel cell carcinomas of the hand and upper extremity. The Surveillance, Epidemiology and End Results database was used to identify all patients with Merkel cell carcinomas of the skin located specifically in the hand and upper extremity. Overall, 5211 cases were identified in the period from 1986 through 2009. The age-adjusted incidence of Merkel cell carcinoma of the hand and upper extremity increased from 0.02 cases per 100,000 in 1986 to 0.14 cases per 100,000 in 2009. The mean age of these patients was 75 years and positive regional lymph nodes were identified in 33%. Rate of metastasis was 4.1%. Overall survival for the study cohort was 49%. Multivariate analysis identified tumor size >5 cm, positive regional lymph nodes and metastasis at diagnosis as independent predictors of mortality. The incidence of Merkel cell carcinomas has increased substantially over the study period. Overall survival for Merkel cell carcinomas of the body and hand and upper extremity is related to tumor size and extent of disease at time of clinical presentation. Merkel cell carcinomas of the hand and upper extremity tend to be diagnosed at an earlier stage with lower rates of regional and systemic spread, and subsequently have a higher overall survival rate.