Spontaneous Rupture of the Extensor Pollicis Longus Tendon: A Systematic Review.

BACKGROUND: Extensor pollicis longus (EPL) rupture and tenosynovitis of the third dorsal compartment is often described in association with a history of rheumatoid arthritis or in the setting of a distal radius fracture. However, the literature suggests multiple other potential factors that may lead to a seemingly spontaneous rupture. METHODS: We performed a systematic review following guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search consisted of headings and keywords related to tendon injuries, tendinopathy, hand surgery, tendon transfer, and injections, as published in reports and studies. Citations were screened by title and abstract against predetermined inclusion and exclusion criteria by 2 independent reviewers, with a third reviewer resolving discrepancies. To be eligible, articles had to meet the following inclusion criterion: describe cases of spontaneous EPL rupture or tenosynovitis of the third dorsal compartment. The exclusion criterion was any history of distal radius fracture or rheumatoid arthritis. RESULTS: We identified 29 articles that met the inclusion criterion. CONCLUSIONS: A myriad of prodromal events or predisposing factors ultimately led to EPL rupture or tenosynovitis of the third compartment. Methods of reconstruction described included primary repair, tendon grafting, and tendon transfer techniques; all with generally good outcomes. These results highlight the inherent fragility of this tendon and support the historical recommendation for early release of the EPL tendon in the setting of tenosynovitis of the third dorsal compartment.

Hand Therapy after Flexor and Extensor Tendon Repair: Assessing Predictors of Loss to Follow-up.

Postoperative hand therapy (HT) is important for regaining function and preventing complications in patients undergoing tendon repair of the hand and wrist. Loss to follow-up (LTFU) can hinder this process; so we sought to determine factors that predict attrition of these patients. Methods: Charts were retrospectively reviewed for patients who underwent extensor or flexor tendon repair of the hand, wrist, or forearm between 2014 and 2019. Demographic data, including age, sex, zip code, employment status, education level, and insurance type, were collected, and the rate of LTFU was calculated. Logistic regression was used to analyze factors. Results: A total of 149 patients were identified and analyzed. The rate of LTFU was 42%. Factors that predicted loss were younger age, male gender, lower educational degree, and a documented psychiatric history. Employment status, insurance type, and distance from the HT center did not predict attrition. The number of HT weeks recommended by the occupational therapist did not differ between those who were lost and those who were not. Lost patients completed, on average, 57% of their suggested HT course. Conclusions: The current study identified demographic factors associated with attrition in patients undergoing tendon repair of the distal upper extremity. Factors included patients who were younger, male gender, less educated, and had a documented psychiatric history. By identifying factors that predict LTFU, specific strategies can be developed to reduce attrition rates, particularly for at-risk populations, to improve patient care after tendon repair.

Back Pain According to Roland-Morris Low Back Pain Scale After Abdominoplasty With Plication: A Prospective Case Series.

INTRODUCTION: Chronic back pain is a physically debilitating condition that affects more than 80% of adults in the United States. A recent case series highlighted how abdominoplasty with plication can offer an alternative surgical approach for treating chronic back pain. These results have been corroborated by a large prospective series. However, this study excluded male and nulliparous subjects, who may also benefit from this surgery. Our group aims to investigate the effect of abdominoplasty on back pain in a more diverse patient population. METHODS: Subjects older than 18 years undergoing abdominoplasty with plication were recruited. An initial survey called the Roland-Morris Disability Questionnaire (RMQ) was administered at the preoperative visit. This questionnaire inquiries about and grades the patient's history of back pain and surgery. Demographic, medical, and social history was also obtained. A follow-up survey and RMQ was then given 6 months after surgery. RESULTS: Thirty subjects were enrolled. Subjects had a mean age of 43.4 ± 14.3 years. Twenty-eight subjects were female and 26 were postpartum. Twenty-one subjects reported initial back pain on the RMQ scale. Of these, 19 reported a decrease in RMQ score after surgery, including male and nulliparous subjects. A significant decrease in mean RMQ score was demonstrated 6 months after surgery (2.94-0.44, P < 0.001). Further subgroup analysis of female subjects demonstrated significantly decreased final RMQ score in parous women, vaginal or cesarean section delivery, and absence of twin gestation. CONCLUSIONS: Abdominoplasty with plication significantly decreases self-reported back pain 6 months after surgery. These results support that abdominoplasty is not purely a cosmetic procedure but can also be applied therapeutically to improve functional symptoms of back pain.

Defining Key Features in Patient Perspectives of Hand Aesthetics.

BACKGROUND: The hand is highly visible and contributes to an individual's aesthetic image and perceived age. Current perspectives on hand aesthetics are primarily based on expert opinion rather than on lay population perspectives, which are less understood. Our study explores general population perceptions on the features that contribute most to an attractive hand. METHODS: Participants rated the attractiveness of 20 standardized hands as well as the appearance based on each characteristic: freckles, hair presence, skin tone, wrinkles, vein appearance, and soft tissue volume. The relative importance of each feature was assessed by comparison with overall attractiveness scores through multivariate analysis of variance. RESULTS: A total of 223 participants completed the survey. Soft tissue volume ( r = 0.73) was most strongly correlated with overall attractiveness, followed by wrinkles ( r = 0.71), skin tone consistency ( r = 0.69), veins ( r = 0.65), freckles ( r = 0.61), and hair ( r = 0.47). Female hands were perceived as more attractive, with a mean rating of 4.7 of 10, compared with 4.4 in males ( P < 0.001). Participants correctly identified the gender of 90.4% of male hands and 65.0% of female hands. Age was strongly inversely correlated with attractiveness ( r = -0.80). CONCLUSIONS: Soft tissue volume is the most important factor in lay perception of hand aesthetics. Female and younger hands were perceived as more attractive. Hand rejuvenation may be optimized by prioritizing soft tissue volume with filler or fat grafting, with secondary priority on resurfacing to address skin tone and wrinkling. An understanding of the factors most important to patients in aesthetic appearance is critical to achieving a pleasing result.

Impending Backlog of Cleft Palate Patients Due to COVID-19.

Coronavirus disease 2019 (COVID-19) has placed an unprecedented strain on healthcare systems worldwide, but while high-income countries (HICs) have been able to adapt, low- and middle-income countries (LMICs) have been much slower to do so due to a lack of funding, skilled healthcare providers, equipment, and facilities. The redistribution of resources to combat the pandemic in LMICs has resulted in decreased surgical volumes at local surgical centers as well as a dramatic reduction in the number of humanitarian aid missions. Despite recent global investment in improving the surgical capacities of LMICs, even in the pre-COVID-19 era there was a vast unmet surgical need. This deficit in surgical capacity has grown during the pandemic and it will be a significant struggle to overcome the resulting backlog of patients. A topic of particular concern to the authors is the effect that the pandemic will have on the delivery of time-sensitive surgical care to patients with cleft palate deformities as delay in providing care can have enormous physical and psychosocial consequences. This paper draws increased attention to the lasting impact that the COVID-19 pandemic may have on cleft palate patients in LMICs. SSRN Pre-print server link: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3898055.

Rapidly Progressive Soft Tissue Infection of the Upper Extremity With Aeromonas veronii Biovar sobria.

Aeromonas veronii, a bacterium found in freshwater, is an unusual pathogen in healthy patients. We present a case report of a rare, aggressive subtype in a young, immunocompetent individual. History of injury in an aquatic environment and culture data are key for identification of the causal agent and should dictate acute clinical management and antibiotic therapy. Coverage should include cephalosporins, quinolones, or sulfas if Aeromonas is suspected, and adjusted depending on culture and sensitivity. Early surgical exploration, incision and drainage, and appropriate antimicrobial therapy are the cornerstones for successful treatment of these aggressive, sometimes life-threatening infections.

Distal Radius Fractures in the Elderly: Use of the Volar Bearing Plate.

BACKGROUND: Distal radius fractures represent some of the most common injuries to the upper extremity, yet current evidence demonstrates great variability in the management of this injury. Elderly patients, in particular, stand to benefit from the early mobilization provided by operative fixation with a volar bearing plate. METHODS: We conducted a retrospective chart review on all patients 65 years or older who underwent unilateral open reduction internal fixation of distal radius fractures using a volar bearing plate at a single institution between January 2014 and January 2016. We excluded patients with bilateral injuries, multiple fractures, and major injuries to the same extremity. RESULTS: Fifty-five patients met criteria for this study. By AO classification, we repaired 17 type A, 24 type B, and 14 type C fractures. At final radiographic measurements, average radial height compared with ulna measured -0.31 mm, average radial inclination measured 20.45 degrees, and average volar tilt measured 7.11 degrees. On discharge, 36 patients had wrist range-of-motion data consistent with a functional wrist. Four patients had limitations in the flexion/extension plane, 8 with radial-ulnar deviation, and 7 had limitations in both planes. CONCLUSIONS: Distal radius fractures in the elderly may successfully be treated with a volar bearing plate. Useful strategies include supraperiosteal dissection of the radius from the pronator quadratus, use of a longer plate for stronger proximal fixation in osteoporotic bone, and regional block. This methodology allows for a safe procedure facilitating the early return of hand and wrist function.

Wieacker-Wolff syndrome with associated cleft palate in a female case.

Wieacker-Wolff syndrome is a rare congenital syndrome with few reported cases in the current literature. It is traditionally described in males as an X-linked recessive disorder associated with congenital contractures of the feet, progressive neurologic muscular atrophy, and intellectual delay caused by ZC4H2 mutations. The purpose of this paper is to present a female individual with a classic phenotype and cleft palate, a previously undescribed finding in this syndrome. Recent reports have demonstrated that females are rarely severely affected and phenotypic expression is difficult to predict [Zanzottera et al. (); American Journal of Medical Genetics Part A 173A: 1358-1363]. This case supports the unpredictability of Wieacker-Wolff syndrome severity and prompts future questions regarding female mutations and phenotypic expression.

Increased Complications in Trapeziectomy With Ligament Reconstruction and Tendon Interposition Compared With Trapeziectomy Alone.

BACKGROUND: In the treatment of basal joint arthritis of the thumb, recent studies suggest equivalent outcomes with regard to long-term pain, mobility, and strength, in patients undergoing either trapeziectomy alone or trapeziectomy with ligament reconstruction and tendon interposition (LRTI). The goal of this study was to investigate risk factors for complications in carpometacarpal (CMC) arthroplasty. METHODS: We conducted a retrospective chart review of 5 surgeons at a single institution performing CMC arthroplasties from November 2006 to November 2012. A total of 200 thumbs in 179 patients underwent simple trapeziectomy with or without LRTI and with or without Kirschner wire stabilization, or a Weilby procedure. The average follow-up was 11.6 months (range = 1-69 months). Data collection included sex, age, history of smoking or diabetes, and any other surgeries performed on the hand at the time of arthroplasty. Furthermore, we collected outcomes involving any adverse events, paying attention to those necessitating reoperation, antibiotics, or those who developed complex regional pain syndrome. RESULTS: Seventy hands had a postoperative complication. Ten of these complications were considered major, defined as requiring antibiotics, reoperation, or other aggressive interventions. On multivariate analysis, risk of total complications was significantly greater only in patients undergoing either trapeziectomy with LRTI or Weilby procedure in comparison with trapeziectomy with K-wire stabilization (odds ratio = 4.30 and 6.73, respectively). CONCLUSIONS: Patients undergoing trapeziectomy with LRTI or Weilby had a greater incidence of reported complications when compared with trapeziectomy alone. These results suggest an advantage of simple trapeziectomy; however, further study is warranted.

Operating room waste reduction in plastic and hand surgery.

BACKGROUND: Operating rooms (ORs), combined with labour and delivery suites, account for approximately 70% of hospital waste. Previous studies have reported that recycling can have a considerable financial impact on a hospital-wide basis; however, its importance in the OR has not been demonstrated. OBJECTIVE: To propose a method of decreasing cost through judicious selection of instruments and supplies, and initiation of recycling in plastic and hand surgery. METHODS: The authors identified disposable supplies and instruments that are routinely opened and wasted in common plastic and hand surgery procedures, and calculated the savings that can result from eliminating extraneous items. A cost analysis was performed, which compared the expense of OR waste versus single-stream recycling and the benefit of recycling HIPAA documents and blue wrap. RESULTS: Fifteen total items were removed from disposable plastic packs and seven total items from hand packs. A total of US$17,381.05 could be saved per year from these changes alone. Since initiating single-stream recycling, the authors' institution has saved, on average, US$3,487 per month at the three campuses. After extrapolating at the current savings rate, one would expect to save a minimum of US$41,844 per year. DISCUSSION: OR waste reduction is an effective method of decreasing cost in the surgical setting. By revising the contents of current disposable packs and instrument sets designated for plastic and hand surgery, hospitals can reduce the amount of opened and unused material. CONCLUSIONS: Significant financial savings and environmental benefit can result from this judicious supply and instrument selection, as well as implementation of recycling.

HISTORIQUE: Les salles d'opération (SO) et les blocs de travail et d'accouchement produisent environ 70 % des déchets hospitaliers. Selon des études antérieures, le recyclage a des conséquences financières importantes pour l'ensemble de l'hôpital. Cependant, son importance n'a pas été démontrée en SO. OBJECTIF: Proposer une méthode pour réduire les coûts grâce à un choix judicieux d'instruments et de fournitures et au recyclage dans le cadre des chirurgies plastiques et de la main. MÉTHODOLOGIE: Les auteurs ont ciblé les fournitures jetables et les instruments qui sont ouverts systématiquement et gaspillés lors des interventions courantes en chirurgie plastique et de la main et ont calculé les économies qui peuvent découler de l'élimination d'articles superflus. Ils ont procédé à une analyse des coûts, dans laquelle ils ont comparé la dépense de déchets en SO au recyclage à flux unique et l'avantage de recycler les documents et les emballages bleus conformément à la HIPAA. RÉSULTATS: Quinze objets ont été retirés des emballages jetables pour la chirurgie plastique et sept autres, des emballages pour la chirurgie de la main. Au total, on pourrait épargner 17 381,05 $US chaque année grâce à ces seuls changements. Depuis le début du recyclage à flux unique, l'hôpital des auteurs a épargné en moyenne 3 487 $US par mois sur ses trois campus. Après extrapolation aux taux d'économie actuels, on s'attendrait à épargner au moins 41 844 $US par année. EXPOSÉ: La réduction des déchets en SO est une méthode efficace pour réduire les coûts en milieu chirurgical. En révisant le contenu des emballages jetables et des emballages d'instruments conçus pour la chirurgie plastique et la chirurgie de la main, les hôpitaux peuvent réduire la quantité d'équipement ouvert et inutilisé. CONCLUSIONS: D'importantes économies et des avantages environnementaux marqués peuvent découler d'un approvisionnement judicieux et d'un choix d'instruments, de même que de l'adoption du recyclage.

Traumatic ulnar artery aneurysm secondary to basketball dunk: a case report and review.

Ulnar artery aneurysms are uncommon lesions. They are often caused by traumatic injury to the hand. Ulnar artery aneurysms have been reported in association with multiple sports-related activities, but never secondary to a basketball injury. The following is a case presentation of an ulnar artery aneurysm likely formed secondary to repetitive basketball slam dunking with accompanying review of diagnosis and surgical treatment of ulnar artery aneurysms.

Frontal sinus repair through a frontalis rhytid approach.

Frontal sinus fractures have traditionally been repaired through a bicoronal approach. This incision provides a wide exposure, but is not without complications, particularly in the patient with or at risk for hairline recession. We present a series of 15 patients who underwent open reduction and internal fixation of anterior table frontal sinus fractures through a frontalis rhytid forehead incision and their results based on the scar appearance, forehead contour, frontalis function, sensation and fracture reduction. Paresthesias cranial to the incision in the supraorbital or supratrochlear distribution were noted in 12 of the 15 patients with resolution in all except 1 patient who did not regain sensation at 4 months follow-up. In all patients, satisfactory forehead contour and fracture reduction were achieved, as were scar appearance and frontalis function at 4 months follow-up. We thus recommend this approach in the treatment of anterior table frontal sinus fractures, with special consideration for the patient with or at risk for anterior hairline recession.

Short-stay cleft palate surgery with intraoperative dexamethasone and marcaine.

The perioperative management of cleft palate surgery remains controversial. Early literature supported hospital stays of 2-5 days, but more recent reports have supported 24-hour admissions in carefully screened patients without congenital syndromes. We retrospectively reviewed 65 cleft palate repairs performed by the senior author from August 1992 through November 2003. Procedures included repairs of the soft palate (n = 25), hard palate (n = 4), or combined hard and soft palate (n = 36). All repairs were performed using a Furlow double, opposing Z-plasty technique. Nine patients (14%) had associated congenital syndromes. Prior to January 1995, patients (n = 15) received perioperative antibiotics and local injection of lidocaine with epinephrine prior to incision. The average operative time to first oral feeding was 13 hours, and the average length of stay in this group was 2.4 days. Previous oral surgery literature has demonstrated the reduction of pain, edema, and trismus with the use of dexamethasone. As part of our recent operative protocol, all patients (n = 50) after January 1995 received perioperative antibiotics, local injection of a 50/50 mixture of 1% lidocaine with epinephrine, and 0.5% Marcaine with epinephrine prior to incision and 4 mg of intravenous dexamethasone perioperatively. The average time to first feeding was 7 hours and the average length of stay was 1.1 days. Postoperatively, patients from both groups were maintained on a liquid or soft diet, depending on their age without the use of bottles. There were no differences in the use of antibiotics or pain management between the 2 groups. Patients were assessed by the surgical team for evaluation of the surgical site and oral intake prior to discharge. Patients in the steroid/Marcaine group had earlier oral intake (P < 0.05) and shorter length of stay (P < 0.05). Of those patients receiving dexamethasone and Marcaine, 43/50 (86%) were discharged within 24 hours. Patients requiring longer hospitalization had initially inadequate oral intake. One patient required readmission for dehydration secondary to rotavirus. In conclusion, short-stay cleft palate surgery is safe, given adequate oral intake, competent parents, and a safe home environment.

Ambulatory alveolar bone grafting.

BACKGROUND: Traditional practice for alveolar cleft closure requires postoperative hospital convalescence in an unfamiliar, disruptive hospital setting. An outpatient iliac crest alveolar bone grafting protocol was devised to optimize patient care. METHODS: A retrospective review of the senior author's experience over 5 years (1998 to 2004) of ambulatory alveolar cleft closure was compared with the previous 5-year period (1993 to 1998) of inpatient convalescence. An iliac crest donor site and standard techniques of alveolar grafting were followed in both groups. Although local analgesia with lidocaine and epinephrine was used in both groups, the ambulatory group received preemptive local anesthesia augmented with Marcaine. Postoperative nausea also was treated preemptively in the outpatient group with the addition of dexamethasone (Decadron) and ondansetron (Zofran), whereas the control patients were treated as needed. Patient charts were reviewed for demographic information, technical aspects, length of donor-site incision, bone graft volume, and time of operation. A Fisher's exact test was used for statistical analysis. Complications including morbidity, readmission, and reoperations were recorded. RESULTS: Twenty consecutive patients were treated on an outpatient basis. Eight consecutive patients were convalesced as inpatients in the previous 5-year period. The ambulatory series average patient age was 12.1 years (range, 8 to 15 years). Four bilateral procedures were performed. The follow-up period averaged 3.5 years (range, 5 to 76 months). Two minor complications were identified: cellulitis at a donor site and a recipient suture line dehiscence with minor graft exposure. There were no readmissions, revision operations, hernias, wound infections, or graft losses identified. In the inpatient series, the average stay was 1.8 days (range, 1 to 3 days). One gingival suture line dehiscence requiring no further intervention was identified, for an average complication rate of 12.5 percent, which was not significant compared with the ambulatory group (10 percent) (p = 1.00). CONCLUSIONS: Alveolar cleft bone grafting using the iliac crest donor site can be safely performed on an outpatient basis when local pain control is followed by predictable anesthetic recovery and sufficient oral intake, and reliable motivated parents or caregivers provide a comfortable postoperative setting. Safe outpatient surgery provides patients and family the opportunity to recover in the familiar home environment.

Carney syndrome and the plastic surgeon: presentation, recognition, and evaluation.

Carney syndrome is a rare clinical entity usually treated by plastic surgeons. We present a patient with Carney syndrome and review the literature emphasising the plastic and reconstructive surgical aspects of the syndrome.