State of the art review: The pathogenesis and management of Madelung deformity.

Madelung deformity remains a fascinating yet unresolved challenge. There is an increasing awareness for early diagnosis by healthcare providers with improvement in diagnostic modalities, however, the exact mechanisms for the development of the deformity have still to be clarified. While some corrective procedures have been described to effectively address an established deformity, the existing literature lacks clear and evidence-based treatment guidelines on how to proceed in daily practice. This review article aims to summarize the current best evidence on this topic, including particular areas of controversy and areas with need for future research.

#MadelungDeformity: Insights Into a Rare Congenital Difference Using Social Media.

BACKGROUND: Madelung deformity is a rare congenital hand difference with little known regarding the patient perspective. In this cross-sectional survey study, we harnessed the global reach of social media to understand the clinical spectrum of Madelung deformity and its impact on physical, mental, and social health. METHODS: A survey was developed based on a previously published protocol and multiple Patient-Reported Outcomes Measurement Information System (PROMIS) short forms. The survey was distributed on several Madelung deformity communities on Facebook and Instagram. T-scores were calculated, interpreted, and compared between patients who underwent surgery and those who did not. Correlations between scores were calculated using the Spearman rank correlation coefficient. RESULTS: Mean PROMIS scores for adults were as follows: pain intensity, 4.9 ± 2.8; pain interference, 57.6 ± 10.0; upper extremity, 35.2 ± 8.1; depression, 53.8 ± 11.1; anxiety, 55.4 ± 11.4; and ability to participate in social roles and activities, 42.5 ± 7.7. Mean scores for children were as follows: pain intensity, 5.0 ± 2.8; pain interference, 55.7 ± 11.3; upper extremity function, 24.6 ± 10.4; depressive symptoms, 57.7 ± 11.3; anxiety, 57.3 ± 11.9; and peer relationships, 42.2 ± 10.3. CONCLUSIONS: Madelung deformity has significant effects on patients' physical, mental, and social well-being, even after surgical treatment. Using social media, we were able to compensate for Madelung deformity's rarity by engaging an international audience, demonstrating the feasibility to conduct research through it, and providing a global perspective of the disease entity.

Madelung Deformity: Radioscapholunate Arthrodesis With a Neo-DRUJ.

BACKGROUND: Madelung deformity is a rare wrist anomaly that causes considerable pain while restricting function. In this study, we describe a radioscapholunate (RSL) arthrodesis with a neo-distal radioulnar joint (DRUJ) in Madelung deformity patients with an abnormal sigmoid notch and compare results to patients after a reverse wedge osteotomy. METHODS: Six wrists underwent RSL arthrodesis with a neo-DRUJ in a two-phase approach: (1) modified RSL arthrodesis with triquetrectomy; and (2) distal scaphoidectomy. Seven wrists underwent a reverse wedge osteotomy procedure. RESULTS: There were no differences found in postoperative pain, grip strength, or range of motion (ROM), apart from extension, which was decreased after RSL arthrodesis with a neo-DRUJ. Quality of life and Michigan Hand Outcomes Questionnaire scores were similar. CONCLUSIONS: Although clinical outcome parameters are not different among the two groups, the RSL arthrodesis with construction of a neo-DRUJ could prove a valid treatment option for a subset of patients with a severely affected sigmoid notch.

Carpal Kinematics in Madelung Deformity.

PURPOSE: Various skeletal and soft tissue abnormalities have been identified in Madelung deformity and have been hypothesized to play a causal role in its progressive symptomatology; however, our pathological understanding of these changes remains limited. In this study, we biomechanically assessed the Madelung deformity wrist, using 4-dimensional computed tomography imaging. METHODS: Nine Madelung deformity wrists (5 patients; age, 24 ± 5 y) and 18 healthy wrists (9 volunteers; age, 28 ± 3 y) underwent 4-dimensional imaging during flexion-extension motion and radioulnar deviation. Carpal kinematics and radiocarpal joint parameters were quantified and compared. RESULTS: In Madelung deformity wrists, significantly decreased rotation was seen in the lunate (-4.6°) and the triquetrum (-4.8°) during flexion-extension motion. During radioulnar deviation, significant decreases were visible in lunate bone translation (-0.7 mm), triquetrum bone translation (-0.6 mm), and triquetrum bone rotation (-1.9°). Patients had significantly decreased articulating surface areas of the scaphoid (1.4 ± 0.2 cm2 versus 1.6 ± 0.2 cm2) and lunate (1.2 ± 0.4 cm2 versus 1.5 ± 0.3 cm2) fossa, and significantly increased radioscaphoid (1.3 ± 0.1 mm versus 1.2 ± 0.1 mm) and radiolunate (1.6 ± 0.2 mm versus 1.3 ± 0.3 mm) joint space thicknesses. CONCLUSIONS: There is a decreased mobility of the lunate and triquetrum bones in Madelung deformity. CLINICAL RELEVANCE: Four-dimensional imaging could be used in future studies that investigate the effect of surgical ligament release on carpal kinematics and subsequent wrist mobility.

Patient-specific plate for navigation and fixation of the distal radius: a case series.

PURPOSE: Corrective osteotomy of a malunited distal radius conventionally relies on 2D imaging techniques for alignment planning and evaluation. However, this approach results in suboptimal bone repositioning, which is associated with poor patient outcomes. In this case series, we evaluate the use of novel patient-specific plates (PSPs), which feature navigation and fixation of bone segments as preoperatively planned in 3D. METHODS: Ten participants with distal radius malunion underwent CT scans for preoperative alignment planning. Patient-specific guides and plates were designed, 3D-printed, and sterilized for use in corrective surgery of the distal radius. Pre- and postoperative results were compared in regard to clinical, functional, and radiographic outcomes. RESULTS: The application of a PSP was successful in 7 of the 10 cases. After treatment, the residual alignment error was reduced by approximately 50% compared with conventional treatment. The use of PSPs reduced pain significantly. Pre- and postoperative results were pooled and demonstrated significant correlations between: (1) pain and malpositioning, (2) the range of pro- and supination motion, the MHOQ score, the EQ-5D-5L score and dorsovolar angulation, and (3) MHOQ score and proximodistal translation. CONCLUSION: The correlation between malalignment and MHOQ score, EQ-5D-5L score, pain, and range of motion shows that alignment should be restored as well as possible. Compared to the conventional approach, which relies on 2D imaging techniques, corrective osteotomy based on 3D preoperative planning and intraoperative fixation with a PSP has been shown to improve bone alignment and reduce pain. LEVEL OF EVIDENCE: IV.

Accuracy of manual and automatic placement of an anatomical coordinate system for the full or partial radius in 3D space.

Accurate placement of a coordinate system on the radius is important to quantitatively report 3D surgical planning parameters or joint kinematics using 4D imaging techniques. In clinical practice, the scanned length of the radial shaft varies among scanning protocols and scientific studies. The error in positioning a radial coordinate system using a partially scanned radius is unknown. This study investigates whether the imaged length of the radius significantly affects the positioning of the coordinate system. For different lengths of the radius, the error of positioning a coordinate system was determined when placed automatically or manually. A total of 85 healthy radii were systematically shortened until 10% of the distal radius remained. Coordinate systems were placed automatically and manually at each shortening step. A linear mixed model was used to associate the positioning error with the length of the radial shaft. The accuracy and precision of radial coordinate system placement were compared between automatic and manual placement. For automatic placement of the radial coordinate system, an increasing positioning error was associated with an increased shortening of the radius (P = < 0.001). Automatic placement is superior to manual placement; however, if less than 20% of the radial shaft length remains, manual placement is more accurate.

Regional incidence of and reconstructive management patterns in melanoma and nonmelanoma skin cancer of the head and neck: A 3-year analysis in the inpatient setting.

INTRODUCTION: Currently, there is limited literature on reconstructive trends for inpatient head and neck skin cancer. Rather, studies have focused primarily on patients treated on an outpatient basis. To gain a better understanding of the effect that reconstructive correction of complex skin cancer defects has on the healthcare system, we examined the existing incidence and reconstructive trends of head and neck melanoma and nonmelanoma skin cancer (NMSC) in the inpatient setting. METHOD: We performed the analysis of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database (NIS) for the years 2012-2014 of the United States (US). Adults diagnosed with melanoma skin cancer or NMSC of the head and neck region were included. Patient characteristics, reconstructive modality, surgical specifics, and outcomes were retrieved. Trends with time for reconstruction techniques were analyzed. RESULTS: In total, 41,185 patients with a diagnosis of skin malignancy were identified, of whom 5,480 (13.3%) underwent reconstruction. Most patients were white (90.0%), male (71.6%), and had a diagnosis of NMSC (79.2%). An increase in flap reconstruction (p < 0.001) was observed. After population adjustment, the highest incidence of skin malignancy was found in the Northeast. CONCLUSION: There has been a trending increase in inpatient NMSC and melanoma skin cancer of the head and neck region, correlating to an increase in the reconstructive procedures performed, and greater cost burden. Resources may be allocated toward early identification and treatment for skin cancer to help control the current rise in complex skin cancer cases necessitating inpatient admission.

International and Geographic Trends in Gender Authorship within Plastic Surgery.

BACKGROUND: Professional advancement in academic plastic surgery may depend on scholarly activity. The authors evaluate gender-based publishing characteristics in three international plastic surgery journals. METHODS: A retrospective review of all articles published in 2016 in the following journals was undertaken: Plastic and Reconstructive Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, European Journal of Plastic Surgery, Annals of Surgery, and New England Journal of Medicine. Data were collected on lead author gender (first or senior author) and differences in author gender proportions, by journal, by article topic, and by geographic location were evaluated. RESULTS: Overall, 2610 articles were retrieved: 34.1 percent were from plastic surgery journals, 12.8 percent were from the Annals of Surgery, and 53.1 percent were from the New England Journal of Medicine. There was a lower proportion of female lead authors among plastic surgery journals compared with the Annals of Surgery and the New England Journal of Medicine (31 percent versus 39 percent versus 39 percent; p = 0.001). There were no differences in female lead author geographic location in the Annals of Surgery or the New England Journal of Medicine; within the plastic surgery journals, there were differences (p = 0.005), including a lower proportion arising from East Asia (15 percent) and a higher proportion arising from Canada (48 percent). Within plastic surgery, Plastic and Reconstructive Surgery had the lowest proportion of female lead author (p < 0.001). The proportion of female lead author varied by article topic (p < 0.001) and was notably higher in breast (45.6 percent) and lower in head and neck/craniofacial-orientated articles (25.0 percent). CONCLUSIONS: There are gender disparities in three mainstream plastic surgery journals-Plastic and Reconstructive Surgery, the Journal of Plastic, Reconstructive and Aesthetic Surgery, the European Journal of Plastic Surgery-and there are lower proportions of lead female authorship compared with the Annals of Surgery and the New England Journal of Medicine. Further research should focus on understanding any geographic disparities that may exist.

Reconstruction of Congenital Microtia and Anotia: Analysis of Practitioner Epidemiology and Postoperative Outcomes.

BACKGROUND: Microtia refers to a congenital malformation of the external ear that is associated with a range of functional, psychosocial, aesthetic, and financial burdens. The aim of this study was to analyze the epidemiology and postoperative complication profile of microtia reconstruction. METHODS: A retrospective review was conducted using data from the 2012-2017 the American College of Surgeons National Quality Improvement Program Pediatric databases. Patients with a diagnosis of microtia or anotia were identified using International Classification of Diseases codes. Demographics and postoperative complications were analyzed using Chi-square and t tests for categorical and continuous variables, respectively. Multivariable regression was performed to control for confounding variables. RESULTS: A total of 466 cases were analyzed, of which 290 (62.2%) were performed by plastic surgeons and 176 (37.8%) by otolaryngologists (ear, nose, and throat physicians [ENT]). Autologous reconstruction was the predominant approach [76.2% of cases (n = 355)] in this cohort. ENT physicians operated on a significantly younger patient population (mean age 8.4 ± 3.2 years versus 10.0 ± 3.2 years, P< 0.001) and had higher rates of concurrent atresia/middle ear repair [21.0% (n = 37) versus 3.7% (n = 17)] compared with plastic surgeons. The rate of all-cause complications was 5.9% (n = 17) in the plastic surgery cohort and 4.0% (n = 7) in the ENT cohort (P= 0.372). Multivariable regression did not reveal any statistically significant predictors for all-cause complications. CONCLUSIONS: Reconstruction of the external ear for patients with microtia/anotia is a safe procedure, with low rates of postoperative complications, readmissions, and reoperations. Autologous reconstruction remains the preferred modality for repair of the external ear and simultaneous atresiaplasty/middle ear repair does not increase the risk of complications.

Quantitative three-dimensional assessment of Madelung deformity.

In the diagnostic work-up of Madelung deformity conventional radiographic imaging is often used, assessing the three-dimensional deformity in a two-dimensional manner. A three-dimensional approach could expand our understanding of Madelung deformity's complex wrist anatomy, while removing inter- and intra-rater differences. We measured previous two-dimensional-based and newly developed three-dimensional-based parameters in 18 patients with Madelung deformity (28 wrists) and 35 healthy participants (56 wrists). Madelung deformity wrists have increased levels of ulnar tilt, lunate subsidence, lunate fossa angle, and palmar carpal displacement. The lunate fossa is more concave and irregular, and angles between scaphoid, lunate, and triquetral bones are decreased. These findings validate the underlying principles of current two-dimensional criteria and reveal previously unknown anatomical abnormalities by utilizing novel three-dimensional parameters to quantify the radiocarpal joint.

Risk factors associated with the development of sepsis after reconstructive flap surgery.

Sepsis is a serious and potentially life-threatening condition. Risk factors that are associated with the development of sepsis may differ as it relates to reconstructive flap surgery. The purpose of this study is to identify the incidence and predictors for sepsis in patients undergoing reconstructive flap surgery. The ACS-NSQIP database was queried from 2005 to 2016 for factors related to sepsis in patients undergoing reconstructive flap surgery. CPT codes were used to identify patient cohorts. A sepsis group was compared to a control group that underwent the same procedures without the postoperative manifestations of sepsis. Statistical analyses were performed to ascertain risk factors associated with the development of sepsis. 24,257 patients who underwent flap reconstruction were included in this study. Of these, 511 developed sepsis postoperatively (2.1%). Multivariate analysis showed that male gender (p < .001), African-American race (p < .001), hypertension requiring medication (p < .001), smoking (p < .001), a higher Charlson comorbidity Index score (p < .001), evidence of preoperative wound infection (p < .001), chronic steroid use (p < .001), and prolonged operative time (p < .001) all significantly were associated with the development of sepsis. Sepsis resulted in a higher chance of 30-day mortality (p < .001) and increased the risk of developing septic shock (OR: 2.578, CI: 1.241-5.354) This study shows that postoperative sepsis is a serious complication of reconstructive flap surgery. Risk reduction and prevention of potentially life-threatening complications is always a priority. Awareness of the risk factors contributing to the development of sepsis is crucial for early intervention and treatment.

The Impact of Resident Postgraduate Year Involvement in Body-Contouring and Breast Reduction Procedures: A Comprehensive Analysis of 9638 Patients.

Given the rising popularity in body-contouring procedures (BCPs) in the United States, it is important to assess the currently unknown association between resident involvement and postoperative complications. As such, the aim of this study was to evaluate the impact of resident involvement on outcomes in BCPs using a large national database. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed (2006-2012) to identify patients undergoing BCPs, using relevant Current Procedural Terminology codes. Outcome measures included postoperative complications, hospital length of stay, and operation time.Multivariate regression models were used to assess the impact of resident involvement and resident experience on outcomes. RESULTS: A total of 9638 cases were identified, of which 3311 involved resident participation.Resident involvement was associated with significantly higher rates of complications (7.8% vs 4.4%; P = 0.003) and longer operation times (180.7 vs 171.9 minutes; P = 0.005). For each year increase of resident postgraduate year, there was a significant decrease in odds of complications (odds ratio, 0.906; P = 0.013) and operative time (-2.7 minutes; P = 0.001). CONCLUSIONS: Resident involvement in BCPs was associated with an increased rate of overall complications in a large, national database. However, the clinical significance of these outcomes may be debated. Increased postgraduate year experience as a surgical resident was inversely associated with overall complications. Guided resident autonomy and earlier exposure to BCPs could lead to an optimization of clinical outcomes and resident education.

Surgical Management of Madelung Deformity: A Systematic Review.

Background: Madelung deformity is a congenital wrist condition characterized by volar subluxation of the wrist caused by premature growth arrest of the distal radius. Progressive symptoms can necessitate surgical intervention, yet optimal treatment strategy remains unknown. The aim of this study is to determine treatment options, surgical indications, and operative outcomes for Madelung deformity. Methods: This study adhered to the Meta-Analyses of Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive systematic review was performed to identify all studies describing surgical interventions for Madelung deformity. All studies were evaluated by level of evidence and a self-developed quality assessment tool. Results: Twenty-five studies met inclusion criteria; all case series with type IV level of evidence. Studies assessed pain, range of motion, aesthetic deformity, and grip strength. The primary indication for surgery was the presence of wrist pain. Various surgical procedures exist and could be categorized as radial lengthening, ulnar shortening, or a combination of both. All studies report postoperative pain reduction and most studies report an improved range of motion. Conclusions: A variety of surgical procedures reportedly have satisfactory outcomes. However, outcomes are reported in an inconsistent manner, prohibiting pooling of studies and comparisons of surgical procedures and their outcomes. We propose several methodological changes for implementation in future studies, increasing the quality of evidence to compensate for small patient numbers.

Institutional Collaboration in Plastic Surgery Research: A Solution to Resource Limitations.

BACKGROUND: The current climate of health care reform and research funding restrictions presents new challenges for academic plastic surgery. Collaboration with private enterprise has been associated with greater research productivity in the general biomedical literature. This study seeks to analyze publication trends in Plastic and Reconstructive Surgery (PRS) to evaluate any changes in institutional collaboration over time. METHODS: Bibliographic data were retrospectively analyzed for all original research and discussion articles published in PRS from 2012 to 2016. The institutional affiliation for each publication was characterized from its author list as solely academic, private, government, or combinations of these (defined here as "institutional collaborations"). Annual National Institutes of Health (NIH) funding data were also collected over the same period, and associations were analyzed by linear regression. RESULTS: In total, 2,595 publications were retrieved from PRS between 2012 and 2016, of which 2,027 (78.1%) originated solely from academic institutions and 411 (15.8%) from institutional collaborations. Although the proportion of academic-only publications decreased from 82% to 74%, the proportion of institutional collaborations increased from 10% to 20% (P = 0.038). Concurrently, NIH funding declined from $33.4 billion to a low of $30.7 billion, which was associated with the decreasing proportion of academic-only publications (P = 0.025) and increasing proportion of institutional collaborations (P = 0.0053). CONCLUSIONS: Traditional sources of academic research funding have been restricted during the politically and financially tumultuous recent years. With no signs of improving access to financial resources from the NIH, academic plastic surgeons may consider diversifying their institutional partnerships to continue pioneering advances in the field.

Prevalence, Clinical Management, and Natural Course of Incidental Findings on Brain MR Images: The Population-based Rotterdam Scan Study.

Purpose To present an updated prevalence estimate for incidental findings on brain magnetic resonance (MR) images and provide information on clinical relevance, including natural course, over a period of up to 9 years. Materials and Methods This study was approved by the institutional review board and all participants gave informed consent. In a prospective population-based setting, structural brain MR imaging was performed in 5800 participants (mean age, 64.9 years; 3194 women [55.1%]). Trained reviewers recorded abnormalities, which were subsequently evaluated by neuroradiologists. The prevalence with 95% confidence interval (CI) of incidental findings was determined, and clinical management of findings that required the attention of a medical specialist was followed. Follow-up imaging in the study context provided information on the natural course of findings that were not referred. Results In 549 of 5800 participants (9.5% [95% CI: 8.7%, 10.3%]), incidental findings were found, of which meningiomas (143 of 5800; 2.5% [95% CI: 2.1%, 2.9%]) and cerebral aneurysms (134 of 5800; 2.3% [95% CI: 2.0%, 2.7%]) were most common. A total of 188 participants were referred to medical specialists for incidental findings (3.2% [95% CI: 2.8%, 3.7%]). Of these, 144 (76.6% [95% CI: 70.1%, 82.1%]) either underwent a wait-and-see policy or were discharged after the initial clinical visit. The majority of meningiomas and virtually all aneurysms not referred or referred but untreated remained stable in size during follow-up. Conclusion Incidental findings at brain MR imaging that necessitate further diagnostic evaluation occur in over 3% of the general middle-aged and elderly population, but are mostly without direct clinical consequences. © RSNA, 2016.

Genetic Determinants of Unruptured Intracranial Aneurysms in the General Population.

BACKGROUND AND PURPOSE: Genome-wide association studies have identified single-nucleotide polymorphisms (SNPs) for intracranial aneurysms in clinical samples. In addition, SNPs have been discovered for blood pressure, one of the strongest risk factors for intracranial aneurysms. We studied the role of these genetic variants on occurrence and size of unruptured intracranial aneurysms, discovered incidentally in a general community-dwelling population. METHODS: In 4890 asymptomatic participants from the Rotterdam Study, 120 intracranial aneurysms were identified on brain imaging and segmented for maximum diameter and volume. Genetic risk scores (GRS) were calculated for intracranial aneurysms (10 SNPs), systolic blood pressure (33 SNPs), and diastolic blood pressure (41 SNPs). RESULTS: The GRS for intracranial aneurysms was not statistically significantly associated with presence of aneurysms in this population (OR, 1.16; 95% CI, 0.96-1.40; P=0.119), but showed a significant association with both maximum diameter (difference in log-transformed mm per SD increase of GRS, 0.10; 95% CI, 0.02-0.19; P=0.018) and volume (difference in log-transformed µL per SD increase of GRS, 0.21; 95% CI, 0.01-0.41; P=0.040) of aneurysms. GRSs for blood pressures were associated with neither presence nor size of aneurysms. CONCLUSIONS: Genetic variants previously identified for intracranial aneurysms in clinical studies relate to the size rather than the presence of incidentally discovered, unruptured intracranial aneurysms in the general population.