Clinical and Histopathological Investigation of Pediatric Melanonychia: A Single-Center Retrospective Case Series.

HYPOTHESIS: The natural history of pediatric melanonychia and the necessity of biopsy for ruling out melanoma are debated in the literature. We hypothesize that there is a low rate of malignant nail pathology among pediatric patients undergoing nail bed biopsy for melanonychia. METHODS: We performed a retrospective chart review of 54 pediatric patients (age <18 years) at a single institution who presented with melanonychia and underwent nail bed biopsy from 2007 to 2022. Data points collected included patient demographics, medical history, physical exam findings, pathology reports, and clinical photos. Univariate and multivariate analyses were performed to assess for risk factors associated with high-risk pathology findings. RESULTS: The average age of melanonychia onset was 5.5 years (SD 4.4). The average age of first biopsy was 7.8 years (SD 4.3). On physical exam, 27 patients had at least four features concerning for melanoma (asymmetry, border irregularity, color heterogeneity, diameter > 1/3 of nail, evolving color, evolving diameter, Hutchinson's sign). The most common pathology diagnoses were melanocytic nevus (35%), atypical intraepidermal melanocytic proliferation (AIMP) with benign features (24%), subungual lentigo (22%), and AIMP with concerning features (17%). There were no cases of melanoma in situ or invasive malignant melanoma. On multivariate regression, the only significant risk factor associated with more concerning pathology (AIMP with concerning features) was the calendar year in which biopsy was performed (coefficient = -0.34, P = 0.016). There was no association between physical exam features and high-risk pathology. Twelve patients had surgical re-excision of the lesion, 6 of which were due to incomplete excision of AIMP with concerning features and 6 of which were due to recurrence. CONCLUSIONS: Our case series did not find any cases of melanoma in situ or malignant melanoma arising from pediatric melanonychia. Atypical intraepidermal melanocytic proliferation with concerning features was associated only with the year in which the biopsy was performed, which may reflect the improved understanding of pediatric melanonychia as often benign despite concerning features on pathology. The decision to perform a nail matrix biopsy in pediatric melanonychia should be based on a collaborative discussion between the patient's parents, dermatologist, and plastic surgeon.

Novel and recurrent variants in PAX6 in four patients with ocular phenotypes from Southeast Asia.

Aniridia is an autosomal dominant condition characterized by the complete or partial absence of the iris, often with additional presentations such as foveal hypoplasia, nystagmus, cataract, glaucoma and other ocular abnormalities. Most cases are caused by heterozygous mutations in the paired box 6 gene (PAX6), which codes for a transcription factor that regulates eye development. Four patients from our hospital who presented with ocular phenotypes were recruited for research sequencing with informed consent. Sanger sequencing of PAX6 coding exons or exome sequencing was performed on genomic DNA from venous blood samples. Variants in PAX6 were identified in the four patients. Two variants are recurrent single-nucleotide substitutions - one is a substitution found in a patient with bilateral aniridia, whereas the other is a splice variant in a patient with nystagmus and neuroblastoma. The other two variants are novel and found in two patients with isolated aniridia. Both are small duplications that are predicted to lead to premature termination. For the recurrent variants, the comparison of phenotypes for patients with identical variants would shed light on the mechanisms of pathogenesis, and the discovery of two novel variants expands the spectrum of PAX6 mutations.

Physeal Fractures of the Distal Ulna: Incidence and Risk Factors for Premature Growth Arrest.

BACKGROUND: The aim of this study is to assess the rate of distal ulnar growth arrest following physeal fracture and to identify specific risk factors for premature physeal closure. METHODS: A retrospective review of patients with a distal ulnar physeal fracture was performed at a single United States children's hospital. Patients without 6-month follow-up were excluded. Patient demographics, injury characteristics, treatment, and outcomes were abstracted. Fractures were classified by the Salter-Harris (SH) system. All follow-up radiographs were reviewed for changes in ulnar variance or signs of premature physeal arrest. RESULTS: Fifty-six children with distal ulnar physeal fracture at a mean age of 10.7±3.3 years were included with a mean follow-up of 1.9 years. The most common fracture pattern was a SH II (52.7%), versus SH I (29.1%), SH III (9.1%), and SH IV (9.1%). Of displaced fractures (41.1%), the mean translation was 40.2±38.3% the and mean angulation was 24.8±20.9 degrees. Eleven fractures (19.6%) demonstrated radiographic signs of growth disturbance, including 3 patients (5.4%) with growth disturbance but continued longitudinal growth and 8 patients (14.3%) with complete growth arrest. The average ulnar variance was -3.4 mm. Three patients underwent subsequent surgical reconstruction including ulnar lengthening with an external fixator, distal ulna completion epiphysiodesis with distal radius epiphysiodesis, and ulnar corrective osteotomy. Patients with displaced fractures and SH III/IV fractures were more likely to develop a growth disturbance (34.8% vs. 3.2%, P =0.003; 50.0% vs. 11.1%, P =0.012, respectively). Children with less than 2 years of skeletal growth remaining at the time of injury had a higher risk of growth disturbance (46.2% vs. 9.5%, P =0.007). CONCLUSIONS: SH III and IV fractures are more common injury patterns in the distal ulna compared with the distal radius. Growth disturbance or growth arrest occurs in ~20% of distal ulnar physeal fractures. Displaced fractures, intra-articular fractures, fractures requiring open reduction, and older children are at increased risk of distal ulnar growth arrest and should be followed more closely. LEVEL OF EVIDENCE: Level IV--case series.

Hand Surgery Questions on the Plastic Surgery In-service Training Examination: Analysis of Content and References.

BACKGROUND: The Plastic Surgery In-service Training Examination (PSITE) provides residents and faculty with an objective evaluation of hand surgery knowledge during plastic surgery residency training. The purpose of this study was to understand tested hand surgery concepts and references to optimize study efforts during plastic surgery residency. METHODS: We reviewed hand surgery questions on 6 consecutive PSITEs (2016-2021). Questions were classified by taxonomy and clinical subject area. Answer references were quantified by source and year of publication. RESULTS: A total of 235 questions tested hand surgery (16% of all PSITE questions) and 60 questions had an associated image (26%). Questions required direct level I-recall (37%), level II-interpretation (28%), and level III-medical decision-making skills (35%). The most frequently tested hand surgery topics were trauma (31%), reconstruction (20%), and functional problems (17%). There were 667 references to 130 unique journals. Journal of Hand Surgery (American volume), 34% and Plastic and Reconstructive Surgery (17%) were the highest yield primary sources. The median lag from publication to PSITE was 7 years (interquartile range, 7 years) with a mode of 2 years. Green's Operative Hand Surgery was the most referenced textbook (54% of textbook references). CONCLUSIONS: This study creates an objective benchmark for hand surgery knowledge training during plastic surgery residency. Efforts focused on the most commonly tested topics and references can enhance resident preparation in hand surgery.

Clinical and operative risk factors for complications after Apert hand syndactyly reconstruction.

This study evaluated how Apert hand syndactyly presentations and reconstructive techniques influence reconstruction outcomes. All cases at a major paediatric hospital between 2007 and 2022 were analysed, including 98 web space reconstructions in 17 patients. Overall, 62% of hands developed complications and 15% required revision surgery. Upton hand type was significantly associated with postoperative complication incidence, specifically including range-of-motion deficits, flexion contracture, web creep and revision surgery. More severe syndactylies may benefit from additional measures to reduce complications. Rectangular commissural flaps showed 1.9 times greater complication risk than interdigitating triangular flaps, including 11.2 times greater risk of web creep. Zigzag volar finger flaps showed 1.8 times greater complication risk than straight-line incisions, including 3.8 times greater risk of web creep. Our study showed that interdigitating triangular commissural flaps and straight-line volar finger incisions are preferable to rectangular commissural and zigzag finger flaps in most cases of Apert hand syndactyly to minimize complications. LEVEL OF EVIDENCE: III.

Natural History of Pediatric Hand and Wrist Ganglion Cysts: Longitudinal Follow-Up of a Prospective, Dual-Center Cohort.

PURPOSE: This investigation describes the outcomes of pediatric ganglion cysts in a prospective cohort that elected not to undergo cyst aspiration or surgical treatment. Our primary aim was to investigate the rate of spontaneous resolution over time among the subset of patients who did not undergo specific treatments. METHODS: Children (aged ≤18 years) who presented to the clinic with ganglion cysts of the hand or wrist were enrolled in a prospective two-center registry between 2017 and 2021. Enrolled subjects who never elected to undergo cyst aspiration or surgical treatment were analyzed. The data collected included age, sex, cyst location and laterality, hand dominance, Wong-Baker pain scale scores, and Patient-Reported Outcome Measurement Information System upper-extremity scores. Follow-up surveys were completed for up to 5 years. RESULTS: A total of 157 cysts in 154 children, with an average age of 9.4 years and a female-to-male ratio of 1.4:1, were eligible. The most common ganglion location was dorsal wrist (67/157, 42.7%), followed by volar wrist (49/157, 31.2%), the flexor tendon sheath (29/157, 18.5%), and the extensor tendon synovial lining (8/157, 5.1%). The average follow-up duration was 2.5 years after initial presentation to the clinic, and 63.1% (99/157) of the patients responded to follow-up surveys. Among them, 62.6% (62/99) of cysts spontaneously resolved; the resolution rates ranged from 51.9% of volar wrist ganglions to 81% of flexor tendon sheath cysts, with an average time to resolution of 14.1 months after cyst presentation. Cysts were more likely to resolve in the hand than in the wrist (84.0% vs 55.4%, respectively). Cysts present for >12 months at initial evaluation were less likely to resolve spontaneously (41.2% vs 67.1%). CONCLUSIONS: Of children who elected not to undergo aspiration or surgical treatment, approximately two-thirds of families reported that their child's ganglion cyst resolved spontaneously. Cysts that resolve spontaneously usually do so within 2 years of presentation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Does Irreducibility Always Mean a Complex Dislocation? An Analysis of 33 Pediatric Metacarpophalangeal Joint Dislocations.

BACKGROUND: Previous failed reduction and certain radiographic indicators historically have been used to differentiate simple and complex metacarpophalangeal joint (MPJ) dislocations in children, the latter of which warrants open reduction. This investigation aimed to determine the necessity for open reduction with these indicators and establish a new treatment algorithm and educational focus for these rare injuries. METHODS: A 12-year retrospective study was conducted on all children with MPJ dislocations at a single pediatric hospital. The rates of successful closed reduction, number of reduction attempts, and radiographic findings were detailed. Operative details and postoperative outcomes were also gathered. RESULTS: Thirty-three patients with a mean age of 11.1 years were included. Most were male [ n = 27 (82%)] and had undergone two or more previous reduction attempts at an outside facility. Stable closed reduction was then achieved outside of the operating room in five patients and in the operating room under general anesthesia in another 14, for a total of 19 of 33 patients (57.6%). The thumb was injured most often [ n = 19 (57.6%)] and more likely to undergo successful closed reduction ( P = 0.04). There was no relationship between number of previous reduction attempts and ability to achieve closed reduction ( P = 0.72). Neither joint-space widening nor proximal phalanx bayonetting was correlated radiographically with failure of closed reduction ( P = 0.22 and P = 1, respectively). CONCLUSIONS: This study supports closed reduction of pediatric MPJ dislocations in the operating room under general anesthesia before conversion to open reduction, regardless of injury characteristics or previous reduction attempts. This strategy is likely to limit unnecessary open surgery and related risks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

An Evolution of the Surgical Management of Synpolydactyly: A Case Series of 21 Hands.

INTRODUCTION: Synpolydactyly is a rare congenital anomaly characterized by syndactyly and polydactyly in the central hand. Limited treatment guidelines exist for this complex condition. METHODS: A retrospective review of synpolydactyly patients was conducted at a large, tertiary pediatric referral center to describe our surgical experience and evolution of management. The Wall classification system was used to categorize cases. RESULTS: Eleven patients (21 hands) with synpolydactyly were identified. Most of the patients were White and had at least one first-degree relative who also had synpolydactyly. The Wall classification yielded the following results: 7 type 1A hands, 4 type 2B hands, 6 type 3 hands, and 4 uncategorizable hands. Each patient had an average of 2.6 surgeries and an average follow-up time of 5.2 years. The rates of postoperative angulation and flexion deformities were 24% and 38%, respectively, with many of these cases also demonstrating preoperative alignment abnormalities. These cases often required additional surgeries including osteotomies, capsulectomies, and/or soft tissue releases. The rate of web creep was 14% with 2 of these patients requiring revision surgery. Despite these findings, at the time of final follow-up, most patients had favorable functional outcomes, were able to engage in bimanual tasks, and were able to perform activities of daily living independently. CONCLUSIONS: Synpolydactyly is a rare congenital hand anomaly with a significant degree of variability in clinical presentation. The rates of angulation and flexion deformities as well as web creep are not insignificant. We have learned to prioritize correcting contractures, angulation deformities, and skin fusion, over simply trying to delete the "extra" number of bones as this may destabilize the digit(s).

Pediatric hand fractures detection on radiographs: do localization cues improve diagnostic performance?

OBJECTIVE: To compare the diagnostic accuracy and interpretation time for detection of pediatric fractures on hand radiographs with and without localization cues. MATERIALS AND METHODS: Consecutive children, who underwent radiographic examinations after injury, over 2 years (2019-2021) and with > 2 weeks of follow-up to confirm the presence or absence of a fracture, were included. Four readers, blinded to history and diagnosis, retrospectively reviewed all images twice, without and with cue, at least 1 week apart and after randomization, to determine the presence or absence of a fracture, and if present, anatomic location and diagnostic confidence were recorded. Interpretation time for each study was also recorded and averaged across readers. Inter-reader agreement was calculated using Fleiss' kappa. Diagnostic accuracy and interpretation time were compared between examinations using sensitivity, specificity, and Mann-Whitney U correlation. RESULTS: Study group included 92 children (61 boys, 31 girls; 10.8 ± 3.4 years) with and 40 (31 boys, 9 girls; 10.9 ± 3.7 years) without fractures. Cue improved inter-reader agreement (κ = 0.47 to 0.62). While the specificity decreased (63 to 62%), sensitivity (75 to 78%), diagnostic accuracy (71 to 73%), and confidence improved (78 to 87%, p < 0.01), and interpretation time (median: 40 to 22 s, p < 0.001) reduced with examinations with localization cue. Specifically, examinations with fracture and cue had the shortest interpretation time (median: 16 s), whereas examinations without fracture and without cue had the longest interpretation time (median: 48 s). CONCLUSION: Localization cues increased inter-reader agreement and diagnostic confidence, reduced interpretation time in the detection of fractures on pediatric hand radiographs, while maintaining diagnostic accuracy.

Evaluating the effectiveness of physical exercise in improving standardized testing performances through attention indices.

INTRODUCTION: In the United States, standardized tests have risen in prevalence, extending their importance from education placement to employment. Attention is crucial to improving testing performance. Past studies have established that acute, coordinative, aerobic exercise improves attention, which is measured by the D2 Attention Test, emotional analysis, reading time, and eye movement tracking. No studies have drawn connections between physical exercise's quantifiable improvement in attention to improvements in standardized tests; therefore, this study would attempt to do so. METHODS: This study defines attention to be positively related to reading speed and negatively related to the number of eye drifts. High school students were selected to read and answer two reading passages from an SAT (Scholastic Assessment Test) exam, before and after a short 80% intensity run. Their reading times, facial video, and test scores were recorded. Dlib plots the facial landmark and OpenCV tracks movement of the pupil. RESULTS: Through paired-samples t-tests, this study found out that after exercise, subjects displayed increased reading speed and fewer eye drifts, coupled with increased mean scores. CONCLUSION: Thus, this study demonstrated that running, as an acute, coordinative, aerobic exercise, helps increase the testing performance of the SAT reading section by measuring attention. Future research could focus on including head movement as an attention index, replicate the experiment on different standardized tests or exercises, and conduct natural experiments to better simulate real-life conditions to increase applicability.

Charting Outcomes in the Hand Surgery Fellowship Match.

PURPOSE: The hand surgery fellowship match attracts applicants from general, plastic, and orthopedic surgery residency training. The purpose of this study was to understand recent trends in applications and match rates in the hand surgery fellowship match. METHODS: The National Resident Matching Program provided program and applicant data from the hand surgery fellowship match (2012-2020). The primary outcomes of interest were match rates and number of unfilled fellowship positions by specialty. Trends over time and comparisons of the percentage of unfilled spots by specialty were observed. RESULTS: The total number of applicants decreased from 199 to 188 (5.5% decrease), while the number of available positions increased from 150 to 177 (18.0% increase) during the study period. The increase in available positions was driven primarily by orthopedic fellowships, which increased from 124 to 149 (20.2% increase). The percentage of applicants that did not match to a hand surgery fellowship decreased from 24.6% in 2012 to 5.9% in 2020. United States graduates had higher match rates than non-United States graduates during each year, but this disparity narrowed over time. Most applicants matched at one of their top 3 choices (first choice, 33.3%; second choice, 12.9%; third choice, 7.9%). Applicants matching at their first choice increased from 28.1% in 2012 to 39.4% in 2020. Plastic surgery hand surgery fellowships had a higher rate of unmatched positions relative to orthopedic surgery fellowships (6.1% vs 2.2%). CONCLUSIONS: Match rates in the hand surgery fellowship match have increased because of an overall increase in training positions and decrease in applicants. More research is needed to understand disparities in match rates by specialty. CLINICAL RELEVANCE: The diverse training experiences of hand surgeons historically have been viewed as a strength for the specialty. Understanding recent trends in the hand surgery fellowship match by specialty can help future applicants and faculty anticipate likely match outcomes.

How is COVID-19 changing the ways doctors make end-of-life decisions?

BACKGROUND: This research explores how the COVID-19 pandemic has changed the ways doctors make end-of-life decisions, particularly around Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR), treatment escalation and doctors' views on the legalisation of euthanasia and physician-assisted suicide. METHODS: The research was conducted between May and August 2021, during which COVID-19 hospital cases were relatively low and pressures on NHS resources were near normal levels. Data were collected via online survey sent to doctors of all levels and specialties, who have worked in the NHS during the pandemic. RESULTS: 231 participants completed the survey. The research found that over half of participants reported making more patients DNACPR than prepandemic, and this was due, at least in part, to an increased focus on factors including patient age, Clinical Frailty Scores and resource limitations. In addition, a sizeable minority of participants reported that they now had a higher threshold for escalating patients to ITU and a lower threshold for palliating patients, with many attributing these changes to formative experiences gained during the pandemic. Finally, our study found that there has not been a statistically significant change in the views of clinicians on the legalisation of euthanasia or physician-assisted suicide since the start of the pandemic. CONCLUSION: The COVID-19 pandemic appears to have altered several aspects of end-of-life decision making, and many of these changes have remained even as COVID-19 hospital cases have declined.

Analysis of Strengths in Exposure to Cases During Plastic and Orthopaedic Hand Surgery Fellowships.

INTRODUCTION: Prospective residents interested in hand surgery must decide to apply for hand surgery fellowships sponsored by different specialties. This study compares case volumes reported during plastic surgery and orthopaedic hand surgery fellowships. METHODS: The American Council for Graduate Medical Education case logs of accredited hand surgery fellowships were analyzed for hand surgery cases (2012 to 2013 to 2020 to 2021). The reported case volume was compared by specialty. Temporal trends were described, intrapathway variabilities calculated, and interpathway differences calculated with Student t -tests. RESULTS: Two hundred plastic surgery (13%) and 1,323 orthopaedic (87%) hand surgery fellows were included. The number of orthopaedic hand surgery fellowships increased from 58 in 2012 to 2013 to 70 in 2020 to 2021 (21% increase), whereas the number of plastic surgery fellowships was stable at 16. Orthopaedic hand surgery fellows reported more hand surgery cases (764 ± 22 versus 628 ± 226), arthroscopy cases (53 ± 54 versus 23 ± 38), and miscellaneous hand surgery cases (42 ± 23 versus 31 ± 18) than plastic surgery hand fellows. Plastic surgery hand fellows reported more cases in wound closure with graft, wound reconstruction with flap, nerve injury, and vascular repair. Overall, orthopaedic surgery offered more experience in 15 case categories (58%), while plastic surgery offered more experience in five case categories (19%). Six case categories (23%) had no difference between specialties. DISCUSSION: Although orthopaedic hand surgery fellowship affords more cases overall, plastic surgery hand fellowships have unique strengths in wound reconstruction with grafts and flaps, nerve injury, and vascular repair. Ultimately, results from this study create a benchmark to improve future training opportunities for hand surgery fellows and orthopaedic surgery residents.

Factors Influencing Why Children and Their Families Choose Surgery for Ganglion Cysts.

PURPOSE: Ganglion cysts of the hand/wrist are frequently managed without surgery but can be treated with surgical excision if there is pain or dysfunction. No studies have examined the specific factors predictive of surgical treatment for pediatric patients. METHODS: This was a study of pediatric patients (≤18 years) with ganglion cysts of the hand/wrist seen between 2017 and 2019 at 2 institutions. Baseline demographic data were collected in addition to cyst characteristics, Wong-Baker pain scores, and Patient-Reported Outcomes Measurement Information System scores (pain, depression, upper extremity function, anxiety). Multivariable regression was used to determine the factors predictive of surgical intervention at ≥6 months of eligible follow-up. RESULTS: A total of 167 patients with a mean age of 10.1 ± 5.3 years were included for analysis. Forty-three (25.7%) underwent surgical excision of their ganglion cyst at means of 2.3 months after the initial visit and 12.6 months after cyst appearance. Sex and cyst location were similar between cohorts. Surgical patients were older (12.1 vs 9.4 years, respectively) and presented to the clinic later after an appearance (10.9 vs 6.5 months, respectively) compared to nonsurgical patients. Surgical patients also had higher pain scores at presentation (median, 3 vs 0, respectively). Cysts receiving surgery were larger than those without surgery (81.4% vs 55.3% >1 cm, respectively). Pain interference Patient-Reported Outcomes Measurement Information System scores were higher in the surgical than the nonsurgical group (45.2 vs 39.6, respectively). In a multivariable analysis, pain scores ≥4 (odds ratio, 3.4) were predictive of surgery for patients ≥3 years, whereas older age (odds ratio, 1.1) and a cyst size >1 cm (odds ratio, 3.3) predicted surgery across all patients. CONCLUSIONS: Pediatric patients with ganglion cysts who initially present at older ages with moderate/severe pain scores and larger cysts are more likely to ultimately choose surgical excision. Surgeons may observe a preference for earlier surgery in this subset of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Recalcitrant Pseudomonas Aeruginosa Keratitis with Hyphaema.

PURPOSE: To report a case of recalcitrant pseudomonas keratitis with a rare presentation of hyphaema. OBSERVATION: A 45-year-old female was noted to have contact lens-related pseudomonas keratitis with hyphaema. The organism was refractory to multiple antibiotics and only responded to Tazocin eye drops. CONCLUSION AND IMPORTANCE: Hyphaema is a rare presentation in bacterial keratitis and could represent infection with an especially virulent organism. Use of Aspirin could precipitate hyphaema in infective keratitis. Alternative antibiotic choices such as Tazocin, colistin, meropenem, and imipenem can be considered when standard therapy is ineffective for multidrug-resistant Pseudomonas keratitis.

Transition to Independent Research Funding Among National Institutes of Health K Grant Awardees at Departments of Orthopaedic Surgery.

BACKGROUND: The National Institutes of Health (NIH) supports mentored research career development awards (K awards) to increase the pipeline of independently funded scientists. This study analyzed the portfolio of K grants that were awarded to orthopaedic surgery departments and characterized the factors that were associated with successful transition to independent NIH research funding, including R01 grants. METHODS: This was a retrospective cohort study of K-award recipients in orthopaedic surgery departments in the United States from 1996 to 2018. A query was performed on the NIH Research Portfolio Online Reporting Tools (RePORT) database for NIH grants that were awarded to departments of orthopaedic surgery, general surgery, otolaryngology, obstetrics and gynecology, ophthalmology, and urology. Rates of transition to independent research funding were compared by specialty for K grants that were awarded from 1996 to 2011. The percentage of faculty with mentored research career development awards and the return on investment (ROI) were calculated. An internet and Scopus (Elsevier) database search determined the investigator characteristics. The factors that were associated with successful transition to independent funding were determined via chi-square and unpaired t tests. RESULTS: Sixty K-award recipients were identified in orthopaedic surgery departments. Most were men (77%) and research scientists (53%). Fifty percent of the K-award recipients transitioned to independent research funding. Research scientists had the highest rate of transition to independent research funding (71%, p = 0.016) relative to clinicians (0%) and orthopaedic surgeons (40%). Higher levels of publication productivity were associated with successful transition to independent research funding. Similar rates of transition to independent research funding existed among surgical specialties (p = 0.107). Orthopaedic surgery had the lowest percentage of faculty with a K award (1.4%) but had the highest ROI (198%) of these awards. CONCLUSIONS: Orthopaedic surgery had similar rates of transition to independent research funding when compared with other surgical specialties but had a lower prevalence of K awards among faculty. Orthopaedic surgeon-scientists have lower rates of transition to independent research funding when compared with their research-scientist colleagues. These findings highlight a need for greater support to foster the pipeline of future NIH-funded orthopaedic investigators. CLINICAL RELEVANCE: As the largest support of biomedical research in the U.S., the NIH is an important stakeholder in orthopaedic innovations and discoveries. This study highlights barriers in the procurement of NIH funding across surgical specialties and affirms the need for greater resources toward supporting NIH funding in orthopaedic surgery.

Clinical Presentation and Characteristics of Hand and Wrist Ganglion Cysts in Children.

PURPOSE: Ganglion cysts are the most common mass of the hand or wrist. In adults, ganglions have a female predilection and are commonly located in the dorsal wrist. However, their presentation in children has not been well reported. This investigation sought to describe the presentation of pediatric ganglion cysts in a prospective cohort. METHODS: A multicenter prospective investigation of children (aged ≤18 years) who presented with ganglion cysts of the hand or wrist was conducted between 2017 and 2019. The data collected included age, sex, cyst location, hand dominance, pain, and patient-reported outcomes measurement information system (PROMIS) scores for upper-extremity (UE) function. The patients were divided into cohorts based on age, cyst location, and cyst size. Multivariable analyses were performed to identify factors predictive of worse UE function and higher pain scores. RESULTS: A total of 173 patients with a mean age of 10.1 ± 5.3 years and female-to-male ratio of 1.4:1 were enrolled. The dorsal wrist was the most commonly affected (49.7%), followed by the volar wrist (26.6%) and flexor tendon sheath (18.5%). In older patients, dorsal wrist ganglions were more common than tendon sheath cysts (11.9 ± 4.1 years vs 6.2 ± 5.8 years) and were larger (86.7% were >1 cm) than cysts in other locations (34.5% were >1 cm). Patients aged >10 years reported higher pain scores, with 21.5% of older patients reporting moderate/severe pain scores versus 5.0% of younger children. This cohort of patients had an average PROMIS UE function score of 47.4 ± 9.5, and lower PROMIS scores were associated with higher pain scores. CONCLUSIONS: Ganglions in pediatric populations, which most commonly affect the dorsal wrist, demonstrate a female predilection. In younger children, cysts are smaller and more often involve the volar wrist or flexor tendon sheath. Older children report higher pain scores. Pediatric ganglion cysts do not appear to result in a clinically meaningful decrease in UE function. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

In Search of Workforce Diversity? A Program's Successful Approach.

SUMMARY: The persistence of health care disparities along racial and ethnic lines highlights the complex and multifactorial nature of this national concern. The paucity of physicians ethnically underrepresented in medicine to treat an ever-growing heterogeneous population inherently contributes to these ongoing disparities. The authors proposed an approach to improve the representation of physicians underrepresented in medicine in their plastic surgery residency program. With a renewed commitment to ethnic diversity and inclusion, a multifaceted recruitment and retention approach was implemented at the University of Pennsylvania plastic and reconstructive surgery residency program from 2015 to 2020 (5 academic years). A retrospective review of the demographics of the program's residents was then assessed over the past 9 academic years for comparison (2011 to 2020). The representation of underrepresented-in-medicine residents within the plastic and reconstructive surgery residency program steadily increased with the implementation of this multifaceted approach, reaching an unprecedented high. Currently, 29 percent of all residents are underrepresented in medicine and 29 percent are female, some of whom are also underrepresented in medicine. Although the female representation is on par with the national average, the underrepresented-in-medicine representation is far greater than the national average. As a result of this multifaceted approach, the representation of African American and Latino plastic surgery residents at the University of Pennsylvania now far exceeds current national averages. Unfortunately, the representation of Native American and Alaskan Natives is still lacking, despite the program's broadened recruitment efforts. The success of this experience describes a successful strategy that institutions can implement to enhance underrepresented-in-medicine representation among its plastic surgery trainees.

Prosthetic versus native artery inflow for infrainguinal bypass.

BACKGROUND: Infrainguinal bypass performed after previous prosthetic inflow reconstruction offers a choice of where to perform the proximal anastomosis. The hood of a previous inflow bypass might be technically easier to isolate during reoperative surgery. However, the more distal native artery might offer better patency to the outflow revascularization. The purpose of the present study was to compare the outcomes of infrainguinal bypass using the hood of a previous inflow bypass vs the native artery as the inflow source. METHODS: A single vascular group's database was queried for all cases of infrainguinal bypass performed after previous prosthetic inflow bypass to a femoral artery from January 2006 to December 2016. The demographics, indications, operative details, and long-term results were recorded and analyzed. Two groups were compared stratified by the location of the proximal anastomosis for the distal bypass. In one group, the inflow source for the distal bypass was from the hood of a previous inflow graft (prosthetic). In the second group, the distal native arterial tree was used as the inflow source. A subset analysis of the patency of the distal bypass was also performed between the two groups for those in which the previous inflow reconstruction had become occluded. Patency was calculated using the Kaplan-Meier method. RESULTS: A total of 197 patients had undergone infrainguinal bypass after previous inflow bypass from 2006 to 2016. Of the 197 procedures, 59 (30%) had used the hood of the previous bypass as the inflow source (prosthetic group) and 138 (70%) had used the native artery distal to the hood of the inflow bypass as the inflow source (native group). The indications were similar between the two groups. The two groups had a similar proportion of men and a similar incidence of hypertension, hyperlipidemia, coronary artery disease, tobacco use, and renal disease. The previous inflow procedures were also similar between the two groups. The native artery used for the inflow source in the native group was the profunda femoris in 80 (58%), common femoral artery in 51 (37%), and superficial femoral artery in 7 (5.1%). Patency was significantly greater for the native group at 1 year (91% vs 75%; P = .0221). Also, the patency after inflow bypass occlusion significantly favored the native group at 1 year (87% vs 40%; P = .0035). CONCLUSIONS: Infrainguinal bypass performed after previous ipsilateral inflow bypass offers the option of using the hood of the bypass or a native artery as the inflow source. The present study demonstrated greater patency rates when using the distal native artery as the inflow source. The native artery option also offered continued patency when the inflow bypass occluded.