International Residents' Perspectives on Education and Challenges in Microsurgery Training.

Objective Microsurgery remains an integral component of the surgical skillset and is essential for a diversity of reconstructive procedures. The apprenticeship also requires overcoming a steep learning curve, among many challenges. The method of microsurgical training differs depending on the countries' regions and resources of their health care system. Methods The Journal of Hand and Microsurgery leadership held an international webinar on June 19, 2021, consisting of a panel of residents from 10 countries and moderated by eminent panelists. This inaugural event aimed to share different experiences of microsurgery training on a global scale, identifying challenges to accessing and delivering training. Results Residents shared various structures and modes of microsurgical education worldwide. Areas of discussion also included microsurgical laboratory training, simulation training, knowledge sharing, burnout among trainees, and challenges for female residents in microsurgical training. Conclusion Microsurgical proficiency is attained through deliberate and continued practice, and there is a strong emphasis globally on training and guidance. However, much remains to be done to improve microsurgical training and start acting on the various challenges raised by residents. Level of Evidence Level V.

Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions.

BACKGROUNDS: Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap. MATERIALS AND METHODS: The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications. RESULTS: The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients. CONCLUSIONS: Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing.

Impaired healing of fragility fractures in type 2 diabetes: clinical and radiographic assessments and serum cytokine levels.

BACKGROUND: Diabetes induces bone alterations accompanied by altered cytokine expression patterns. These alterations lead to modified fracture healing, contributing to musculoskeletal fragility in the elderly. AIMS: We evaluated the inflammatory immune response in diabetic patients during fracture healing relative to clinical and radiographic assessments. METHODS: Fifty patients of both sexes with fragility fractures were studied: 30 diabetics (group A, mean age 73.4 ± 11.2 years) and 20 normoglycemic controls (group B, mean age 75.1 ± 16.9 years). Two subgroups comprised those with hip or wrist fragility fractures (25 and 16 patients, respectively). We evaluated serum concentrations of tumor necrosis factor α, interleukins 4 and 8, monocyte chemotactic protein-1 (MCP-1), vascular endothelial growth factor, and epidermal growth factor (EGF) before and at 4 and 8 weeks after surgery. We also determined the Radiographic Union Score for Hips and the Radius Union Scoring System score and applied the Physical Activity Scale for the Elderly test at the same time points. Each patient underwent bone densitometry. RESULTS: MCP-1 and EGF levels were higher in group A than in group B at 4 weeks after surgery (p > 0.05). Radiographic evaluation showed lower scores in group A (p < 0.05). The main difference between the groups was evident 4 weeks after surgery. Changes in the serum concentrations of chemotactic and angiogenic factors could explain the radiographically proved impaired fracture healing in diabetic patients. CONCLUSIONS: Fragility fracture healing is impaired in diabetic patients. Radiographic and molecular patterns confirmed that the most compromised fracture-healing phase is at 4 weeks after surgery, during callus mineralization.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines.

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.