Kinematic Investigation of Healthy, Arthritic, and Postsurgery Thumbs: Is the Metacarpophalangeal Joint the Gateway to Carpometacarpal Arthritis?

The thumb carpometacarpal (CMC) joint is one of the most likely joints to develop osteoarthritis (OA). If conservative treatments fail to alleviate symptoms, surgery may be pursued. Kinematic outcomes of CMC surgery techniques have been described, but current tools have limitations in capturing motion abilities. The goals of this study were (1) develop a new and robust set of kinematic outcome measures, and apply them to (2) a cohort of younger and older control individuals without CMC OA to determine age and sex-related changes, and (3) a cohort of participants with CMC OA before, 3 months, and 6 months after undergoing thumb ligament reconstruction with tendon interposition surgery to detect the impacts of surgery. 52 (26 males, 26 females) control and 18 (3 males, 15 females) surgical participants were tested. Kinematics were investigated using motion capture by mapping the three-dimensional motion space of the whole thumb, and two-dimensional motion boundaries of the metacarpal (MC) and proximal phalange (PP). Visual analog pain score was recorded. Older control participants had shifted regions of motion compared to younger participants (p ≤ 0.027), suggesting asymptomatic CMC wear. Control females had 31% more metacarpophalangeal (MCP) motion than control males (p = 0.013), which could alter loading paths through the CMC joint and increase OA risk. Pain at 6 months postsurgery was 72% less than presurgery (p < 0.001), but motion abilities were 20-28% less than presurgery (p ≤ 0.074) and 24-40% less than control participants (p ≤ 0.066). These techniques have the possibility of identifying presymptomatic motion changes, including those at the metacarpophalangeal joint in CMC OA progression.

Preoperatively Identified Sarcopenia Leads to Increased Postoperative Complications, Hospital and ICU Length of Stay in Autologous Microsurgical Breast Reconstruction.

BACKGROUND: Sarcopenia is a condition characterized by the loss of skeletal muscle mass and strength. Recently, there has been a tremendous amount of research into the prognostic value of sarcopenia in surgical outcomes. The purpose of this study was to compare postoperative outcomes in free flap breast reconstruction in patients with and without sarcopenia. METHODS: One hundred three patients who underwent autologous breast reconstruction from 2013 to 2016 were studied. The cross-sectional area (CSA) of skeletal muscle was measured from preoperative computed tomography images at L3 using the National Institutes of Health ImageJ software. CSA was then normalized to patient stature by dividing CSA by height (cm2/m2). A previously published skeletal muscle index cutoff of 38.5 cm2/m2 was used to define sarcopenia. Intraoperative and postoperative surgical outcomes were recorded retrospectively. Outcomes were analyzed using multivariate, univariate, and regression statistics. RESULTS: Eight of the 103 (7.8%) patients were found to have sarcopenia. Sarcopenia was associated with a statistically significant increase in flap site delayed healing (37.5% vs. 20%, p = 0.046), take back to the operating room (25% vs. 11.6%, p = 0.05), intensive care unit length of stay (1.5 vs. 0.02 days, p < 0.0005), and hospital length of stay (8.38 vs. 5.49 days, p < 0.0005) when compared with patients without sarcopenia. There were no significant differences in flap loss, surgical site infection, hematoma, seroma, donor site delayed healing, intraoperative complications, and number of revision surgeries. CONCLUSION: Sarcopenia is significantly associated with increased complications in patients undergoing free flap breast reconstruction. Further investigation into the biochemical and physiologic changes associated with sarcopenia is needed.

Tourniquet Use in Wide-Awake Carpal Tunnel Release.

Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.

Female-to-Male Gender-Confirming Drainless Mastectomy May Be Safe in Obese Males.

BACKGROUND: Gender dysphoria is a medical condition associated with suicidality. Transgender men who have undergone female-to-male (FTM) chest reconstruction report higher quality of life and reduced gender dysphoria. It has been reported that transgender men are at higher risk of obesity. OBJECTIVES: The objective of this study was to compare perioperative outcomes and complications between different classes of obesity in FTM transgender patients who underwent chest masculoplasty. METHODS: A retrospective review of 145 consecutive patients who underwent mastectomy with free nipple graft was conducted. Postoperative outcomes and complications were collected. Patients were divided into nonobese (body mass index [BMI] <30 kg/m2), obese (BMI 30-39.9 kg/m2), morbidly obese (BMI 40-49.9 kg/m2), and super obese (BMI >50 kg/m2) groups. RESULTS: Sixty-six of the 145 patients were not obese, 52 were obese, 22 were morbidly obese, and 5 were super obese. There was a statistically significant increase in amount of breast tissue resected between each of the 4 groups (866.8 g vs 1672.4 g vs 3157.1 g vs 4827.6 g; P ≤ 0.0005) as BMI increased, respectively. There was a significant difference in operative time between the nonobese and obese groups (128.7 vs 134.6 vs 150.5 vs 171 minutes; P = 0.026). A significant increase in postoperative infections was observed between the morbidly obese, super obese, and the nonobese group (P = 0.048). CONCLUSIONS: Chest wall reconstruction in FTM and nonbinary transgender people is important in relieving gender dysphoria. Postoperative complications were not significantly increased in obese patients (30-39.9 kg/m2). Delaying surgery for weight loss may not be necessary unless patients are morbidly obese.

Surgical Management of Spasticity of the Forearm and Wrist.

Upper extremity spasticity may result from a variety of types of brain injury, including cerebral palsy, stroke, or traumatic brain injury. These conditions lead to a predictable pattern of forearm and wrist deformities caused by opposing spasticity and flaccid paralysis. Upper extremity spasticity affects all ages and sociodemographics and is a complex clinical problem with a variety of treatment options depending on the patient, the underlying disease process, and postoperative expectations. This article discusses the cause, diagnosis, operative planning, operative techniques, postoperative outcomes, and rehabilitation protocols for the spastic wrist and forearm.

Combined Carpal Tunnel Release and Palmar Fasciectomy for Dupuytren's Contracture Does Not Increase the Risk for Complex Regional Pain Syndrome.

BACKGROUND: Hand surgery dogma suggests that simultaneous surgical treatment of carpal tunnel syndrome and Dupuytren's contracture results in an increased incidence of complex regional pain syndrome. As a result, many surgeons do not perform surgery for the two conditions concurrently. The authors' goal was to determine the extent of this association. METHODS: The authors identified all patients undergoing surgical treatment for carpal tunnel syndrome, Dupuytren's contracture, or both between April of 1982 and March of 2017 using the Indiana Network for Patient Care, a large, multi-institutional, statewide information exchange. Demographics, comorbidities, and 1-year postoperative incidence of complex regional pain syndrome were recorded. RESULTS: A total of 51,739 patients (95.6 percent) underwent carpal tunnel release only, 2103 (3.9 percent) underwent palmar fasciectomy only, and 305 (0.6 percent) underwent concurrent carpal tunnel release and palmar fasciectomy. There was no difference in the likelihood of developing complex regional pain syndrome (p = 0.163) between groups. Independent risk factors for developing complex regional pain syndrome were younger age; anxiety; depression; epilepsy; gout; and history of fracture of the radius, ulna, or carpus. CONCLUSIONS: Concurrent carpal tunnel release and palmar fasciectomy is not associated with an increased risk for developing complex regional pain syndrome. Patient demographics, medical comorbidities, and a history of upper extremity trauma are associated with the development of complex regional pain syndrome after surgery and should be discussed preoperatively as potential risk factors. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Scholarly activity in academic plastic surgery: the gender difference.

BACKGROUND: The number of women in medicine has grown rapidly in recent years. Women constitute over 50% of medical school graduates and hold 38% of faculty positions at United States medical schools. Despite this, gender disparities remain prevalent in most surgical subspecialties, including plastic surgery. The purpose of this study was to analyze gender authorship trends. MATERIALS AND METHODS: A cross-sectional study of academic plastic surgeons was performed. Data were collected from departmental websites and online resources. National Institute of Health (NIH) funding was determined using the Research Portfolio Online Reporting Tools database. Number of published articles and h-index were obtained from Scopus (Elsevier Inc, New York, NY). Statistical analysis was performed in SPSS (SPSS Inc, Chicago, IL). RESULTS: A total of 814 plastic surgeons were identified in the United States. Compared to men, women had significantly fewer years in practice (P <0.001), lower academic ranks (P <0.001), and published less (P <0.001). There was no difference in the number of PhD degrees between genders; women with PhDs published less than men with PhDs (P = 0.04). 5.1% of women and 6.9% of men received NIH funding during their career (P = 0.57). There was no gender difference in scholarly output among NIH-funded surgeons. Overall, years in practice, academic rank, chief/program director title, advanced degrees, and NIH funding all positively correlated with academic productivity. CONCLUSIONS: This study identifies significant gender disparities in scholarly productivity among plastic surgeons in academia. Future efforts should focus on improving gender equality and eliminating barriers to academic development.

Do Plastic Surgery Programs with Integrated Residencies or Subspecialty Fellowships Have Increased Academic Productivity?

UNLABELLED: The aim of this study was to evaluate the effect of different surgical training pathways on the academic performance of plastic surgical divisions. METHODS: Eighty-two academic parameters for 338 plastic surgeons (PS), 1737 general surgeons (GS), and 1689 specialist surgeons (SS) from the top 55 National Institutes of Health (NIH)-funded academic departments of surgery were examined using data gathered from websites, SCOPUS, and NIH Research Portfolio Online Reporting Tools. RESULTS: The median size of a PS division was 7 faculty members. PS faculty had lower median publications (P)/citations (C) (ie, P/C) than GS and SS (PS: 25/328, GS: 35/607, and SS: 40/713, P < 0.05). Publication and citation differences were observed at all ranks: assistant professor (PS: 11/101, GS: 13/169, and SS: 19/249), associate professor (PS: 33/342, GS: 40/691, and SS: 44/780), and professor (PS: 57/968, GS: 97/2451, and SS: 101/2376). PS had a lower percentage of faculty with current/former NIH funding (PS: 13.5%, GS: 22.8%, and SS: 25.1%, P < 0.05). Academic productivity for PS faculty was improved in integrated programs. P/C for PS faculty from divisions with traditional 3-year fellowships was 19/153, integrated 6-year residency was 25/329, and both traditional and 6-year programs were 27/344, P < 0.05. Craniofacial and hand fellowships increased productivity within the integrated residency programs. P/C for programs with a craniofacial fellowship were 32/364 and for those that additionally had a hand fellowship were 45/536. PS faculty at divisions with integrated training programs also had a higher frequency of NIH funding. CONCLUSIONS: PS divisions vary in degree of academic productivity. Dramatically improved scholarly output is observed with integrated residency training programs and advanced specialty fellowships.