Recent Advancements in the Diagnosis and Treatment of Congenital Hand Differences.

Congenital hand and upper limb differences include a wide spectrum of structural abnormalities that affect functional, appearance, and psychosocial domains of affected children. Ongoing advances in the understanding and treatment of these differences continue to shape management. Over the past 10 years, new developments have been made in areas of molecular genetics, noninvasive treatments, surgical techniques, and outcome measures in several commonly seen congenital hand differences. Applying these advances in knowledge and management of congenital hand differences will enable surgeons to achieve the best outcomes possible for these children.

Regional Anesthetic Blocks for Donor Site Pain in Burn Patients: A Meta-Analysis on Efficacy, Outcomes, and Cost.

BACKGROUND: Skin graft donor site pain significantly affects pain management, narcotic use, and hospital length of stay. This study is intended to evaluate the efficacy of regional anesthesia in the burn population to decrease narcotic consumption and to assess the impact on hospitalization costs. METHODS: PubMed/MEDLINE, Embase, and ScienceDirect were searched with the following inclusion criteria: comparative studies, adult populations, burn patients, autologous skin grafting, regional nerve blocks, and traditional narcotic regimens. Outcomes assessed included narcotic consumption, pain scores, and opioid side effects. Meta-analysis obtained pooled values for morphine consumption and side effects. Cost analysis was performed using published data in the literature. RESULTS: Final analysis included 101 patients. Cumulative morphine consumption at 72 hours was lower for patients treated with regional anesthesia versus patient-controlled analgesia (PCA; single shot 25 ± 12 mg, continuous regional 23 ± 16 mg, control 91.5 ± 24.5 mg; P < .05). Regional anesthesia decreased nausea/vomiting (P < .05) and lowered subjective pain scores. Regional anesthesia interventions cost less than PCA, single shot less than continuous (P < .05). CONCLUSION: Regional anesthesia at skin graft donor sites significantly decreases narcotic consumption in burn patients. Regional anesthesia is cost-effective, decreases side effects, and may result in shorter hospital stays due to improved pain management.

HISTORIQUE: La douleur aux sites donneur des greffes de peau a une influence importante sur la gestion de la douleur, la consommation de narcotiques et la durée de l'hospitalisation. La présente étude vise à évaluer l'efficacité de l'anesthésie régionale au sein de la population de brûlés pour réduire la consommation de narcotiques et à en examiner les effets sur les coûts d'hospitalisation. MÉTHODOLOGIE: Les chercheurs ont utilisé les critères d'inclusion suivants pour effectuer leurs recherches dans PubMed/MEDLINE, Embase et ScienceDirect : études comparatives, populations adultes, patients brûlés, greffes de peau autologues, blocs nerveux régionaux et posologies classiques de narcotiques. La consommation de narcotiques, les scores de douleur et les effets secondaires des opioïdes étaient les résultats secondaires évalués. La méta-analyse a donné des valeurs groupées de consommation et d'effets secondaires de morphine. L'analyse des coûts a été exécutée au moyen des données publiées. RÉSULTATS: L'analyse finale incluait 101 patients. La consommation cumulative de morphine au bout de 72 heures était plus faible chez les patients traités par anesthésie régionale que chez ceux qui contrôlaient leur propre analgésie (une seule infusion 25 ± 12 mg, infusion régionale continue 23 ± 16 mg, sujets témoins 91,5 ± 24,5 mg; p < 0,05). L'anesthésie régionale réduisait les nausées et les vomissements (p < 0,05), de même que les scores de douleur subjective. L'anesthésie régionale est moins coûteuse que celle contrôlée par le patient, et une seule infusion, moins chère qu'une infusion continue (p < 0,05). CONCLUSION: L'anesthésie régionale aux sites donneur des greffes de peau réduit considérablement la consommation de narcotiques chez les patients brûlés. L'anesthésie régionale est économique, réduit les effets secondaires et peut raccourcir le séjour hospitalier grâce à une meilleure gestion de la douleur.

Nasal Obstruction and Rhinoplasty: A Focused Literature Review.

BACKGROUND: There is a significant variation in the assessment, treatment, and outcomes of nasal airway obstruction and management in the published literature. This study aimed to: (1) define key components of the nasal airway, (2) identify frequent causes of nasal obstruction, and (3) review existing treatment methods. METHODS: A systematic review of the literature was performed, and 135 studies were included via the following criteria: English, human subjects, and a primary endpoint of nasal airway improvement. Exclusion criteria were: abstract only, no airway data, pediatric patients, cleft rhinoplasty, sleep apnea, isolated traumatic nasal reconstruction, and cadaveric-only or animal studies. RESULTS: The relevant obstructive sites include the ENV, septum, inferior turbinates, INV, and nasal bones. Addressing the alar rim alone may be insufficient, and inspection of the lateral wall and crura may be indicated. Correction of septal deviation involves attention to the bony base. Mucosal sparing treatment of inferior turbinates improves outcomes. INVs are a major source of nasal obstruction, and treatment includes spreader grafts. The bony nasal vault can contribute to nasal obstruction, including due to surgical osteotomies. CONCLUSIONS: Anatomic causes of airway obstruction include the alar rims and lateral nasal walls, deviated nasal septum, inferior turbinate hypertrophy, decreased INV angle, and narrowed nasal bones. Treatments include graft placement; septoplasty; mucosal sparing turbinectomy; and lateral wall support. Pitfalls include failing to address the bony septum, over-resection of inferior turbinates, and narrowing of the nasal vault. Appreciation of airway management during rhinoplasty will improve functional outcomes. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Craniofacial Skills: A 2-Site Validation of Assessments to Aid Plastic Surgery Resident Milestone Achievement in Technical Skills and Instrument Knowledge.

BACKGROUND: Plastic surgery evaluates residents on milestones. This study defines a model of education including pre and post-test assessments paired with didactics intended for evaluating residents in the unique technical skills of craniofacial surgery. METHODS: At the first institution, instrument identification, and time/accuracy of burr hole placement, craniotomy, and plating on Saw Bones Craniofacial Models were tested before and after a 7.5-hour craniofacial orthognathic surgery workshop. At the second institution, this was refined, removing plating, eliminating assessment of timing, and shortening didactics to standard osteotomies, instrument names, and common surgical approaches. The study population consisted of junior, mid-level, and senior residents on 2 different University craniofacial services. RESULTS: Participant performance was analyzed by level of training: junior, midlevel and senior resident. In the first iteration, resident times improved significantly for all 4 tasks (P = 0.008, 0.035, 0.035, 0.016). Resident accuracy improved significantly for instrument naming (P = 0.003). Except for instrument naming, resident year did not impact improvement (timing: P = 0.062, 0.310, 0.125, 0.334; accuracy: P = 0.029, 0.664, 0.717, 0.306). In the second iteration, resident accuracy improved for all tasks (instrument naming P = 0.00002, burr holes P = 0.0031, craniotomy P = 0.08). There was no difference in rate of improvement between resident cohorts. CONCLUSION: The task-based assessment with resident education on basic craniofacial surgery skills, standard osteotomies, and instrument names directed resident learning and assessed resident knowledge. With the removal of time as a metric, all tasks improved in accuracy. The craniofacial skills task-assessment successfully evaluated milestone attainment in a reproducible model.

Fibrin tissue sealant and minor skin grafts in burn surgery: A systematic review and meta-analysis.

BACKGROUND: The indications for use of fibrin glue in skin grafting burn patients remains understudied. The purpose of this study is to review the efficacy of fibrin tissue sealant in skin graft adherence, establish guidelines for use of fibrin tissue sealant, and review the cost effectiveness of fibrin glue. METHODS: Publications with the following criteria were included: comparative human studies, autologous skin grafts, and autologous or commercial fibrin sealant. Outcomes assessed included evidence of engraftment, wound closure, rates of hematoma/seroma, graft loss and infection. Meta-analysis obtained pooled odds ratios for outcomes of interest. Cost analysis was performed using data available in the literature. RESULTS: 7 studies and 751 interventions (fibrin) and controls (staples) were included in the final analysis. 67.6% grafts with fibrin were 100% adherent by one week, vs. 55.5% (OR 1.45, p = 0.086). Complete wound closure by one month was 80.2% with fibrin, vs. 73.3% (OR 1.34, p = 0.187). Hematoma/seroma occurred 38.2% with fibrin, vs. 64.7% (OR 0.487, p = 0.122). Graft loss was higher in the control group, 21% vs. 12.6% (OR 0.891, p = 0.604). Average cost of fibrin glue was $50 per ml, and averaged costs of stapler and staple remover was $30 USD ($10-50). CONCLUSION: Fibrin glue is as effective as staples for adhering skin grafts, and trends towards lower rates of hematoma/seroma. In topographically complex regions, fibrin glue may be a better choice for adherence of skin grafts.

Human papillomavirus vaccine stages of change among male and female university students: ready or not?

OBJECTIVE: To examine gender differences in human papillomavirus (HPV) vaccine stages of change following the recommendations for permissive use of HPV vaccine in males. PARTICIPANTS: Students aged 18-26 attending a large, public, Midwest university in April 2010. METHODS: Participants completed a self-administered, online questionnaire. HPV vaccine stage of change was assessed according to core constructs of the Transtheoretical Model of Behavior Change. Logistic regression was used to identify associations of HPV-related beliefs and attitudes with stage of change. RESULTS: Although most (80.5%) of the 4,019 participants had at least contemplated HPV vaccination, more females had taken observable steps towards vaccination. Significant differences between genders in HPV-related beliefs and attitudes were observed, particularly perceived parental or perceived health care provider approval of HPV vaccination. CONCLUSIONS: University students generally agreed with the benefits of HPV vaccination, both for themselves and for society, and these attitudes were significantly associated with having at least contemplated vaccination.