Management of isolated volar lunate facet fractures of the distal radius.

Distal radius fractures are among the most common fractures treated globally. Consideration of the mechanism of injury and careful radiographic assessment contributes to appropriate management of these injuries in isolation or jointly with other fractures or injuries affecting the wrist joint. Treatment options can range from non-operative management to a variety of fixation techniques. Interest in the distal radius fractures was renewed as open reduction and monoblock volar locking plate fixation became the preferred contemporary treatment in the last few decades. Isolated volar lunate facet (VLF) fractures are uncommon. However, the stability of the entire carpus may be compromised with fractures of the volar marginal rim. Inadequately or improperly treated fractures of the VLF can lead to significant long-term complications. A critical approach to this unique fracture pattern's evaluation, management, and surgical fixation is paramount for successful and reproducible outcomes in stability and durability.

Overview and management of complications after digital replantations.

The main complications after digital replantation are discussed in this review article. These complications include vascular compromise, infection, partial necrosis, delayed union or nonunion, atrophy and so on. The countermeasures for these complications are reviewed and the authors' methods are also introduced and discussed.

Analysis of Postoperative Distal Radius Fracture Outcomes in the Setting of Osteopenia and Osteoporosis for Patients with Comorbid Conditions.

Purpose: Distal radius fractures (DRFs) are among the most common orthopedic injuries, especially in the elderly. A wide variety of approaches have been advocated as successful treatment modalities; yet, there remains variability in practice patterns of DRF in patients with osteoporosis and osteopenia. Using large data set analysis, we sought to determine the risk profile of operative fixation of DRF in patients with low bone mineral density. Methods: A commercially available health care database, PearlDiver, was queried for all patients who underwent open reduction internal fixation of DRFs between 2010 and 2020. The study population was divided into groups based on the presence or absence of osteopenia or osteoporosis and was further classified by patients who were receiving bisphosphonate therapy. Complication rates were calculated, including rates of malunion, surgical site infection, osteomyelitis, hardware failure, and hardware removal. Five-year future fragility fractures were defined in hip, vertebrae, humerus, and wrist fractures. Chi-square analysis and logistic regression were performed to determine an association between these comorbidities and various postoperative complications. Results: A total of 152,926 patients underwent open reduction internal fixation of a DRF during the study period. Chi-square analysis of major complications at 3 months showed a statistically significant increase in malunion in patients with osteopenia (P = .05) and patients with osteoporosis (P = .05) who underwent open reduction internal fixation. Logistic regression analysis at 12 months after surgery demonstrated that osteopenia was associated with an increased risk of hardware failure (P < .0001), hardware removal (P < .0001), surgical site infection (P < .0001), and malunion (P = .004). Osteoporosis was associated with a significantly increased risk of hardware failure (P = .01), surgical site infection (P < .0001), and malunion (P < .0001). Conclusions: We demonstrated, using large data set analysis, that DRF patients with osteopenia and osteoporosis are predicted to be at increased risk of multiple postoperative complications, and thus, bone density should be strongly considered in treatment planning for these patients. Type of study/level of evidence: Prognostic III.

Analysis of Complications in Patients With a History of Cannabis Use and Tobacco Use Undergoing Implant-Based Breast Reconstruction.

BACKGROUND: There is limited information regarding the perioperative effects of marijuana in breast reconstructive surgeries. OBJECTIVES: The objective of this study was to explore the association between a history of cannabis use and postoperative complications in the setting of implant-based breast reconstruction. METHODS: Two databases, TriNetX and PearlDiver, were queried for patients undergoing implant-based breast reconstruction. Patients were divided into 4 groups based on active ICD-10 diagnostic codes: (1) cannabis use only, (2) tobacco use only, (3) cannabis and tobacco use, and (4) neither cannabis nor tobacco use. Associations with postoperative complications were analyzed with a logistic regression test. RESULTS: TriNetX search revealed that 327 patients had an active diagnosis of cannabis use only and 1118 had an active diagnosis of tobacco use only. Patients in the cannabis only cohort had a significantly increased risk of developing surgical site infection. Patients in the tobacco only cohort had significantly increased risk of developing wound dehiscence, need for debridement, and surgical site infection. The PearlDiver search included 472 patients who had an active diagnosis of both cannabis and tobacco use and 17,361 patients with a diagnosis of tobacco use only. Patients with a diagnosis of cannabis and tobacco use had a significantly increased risk of developing postoperative complications including surgical site infection, wound dehiscence, need for incision and drainage, and debridement. CONCLUSIONS: Patients undergoing implant-based breast reconstruction with an active diagnosis of cannabis with or without tobacco use were at increased risk of developing postoperative complications, and the risk was even higher in patients using both tobacco and cannabis.

Outcomes following replantation surgery.

The ability to perform surgical replantation of individual digits and limbs can provide substantial functional improvement for patients who sustain devastating upper extremity injuries. Defining success in replantation surgery extends beyond the acute period and the binary metrics of survival or loss of the replanted part to include the long-term overall functional outcomes. Functional outcomes include both objective clinical evaluation and patient-reported outcomes. There has been significant variation in the way outcomes following replantation are measured, which inherently leads to heterogeneity in the reported outcome data. Given the variability among outcome measures, we aim to explore the outcomes of replantation surgery, particularly clinical evaluation and patient-reported functional outcomes following replantation.

Ulnar Nerve Compression at the Elbow Secondary to Intramuscular Lipoma of the Flexor Carpi Ulnaris: A Case Report.

CASE: A 62-year-old right-hand-dominant woman presented with 1 year of persistent radiating pain, weakness, and paresthesias in her left forearm and hand. Electromyography findings were significant for ulnar neuropathy distal to the branch innervating the flexor carpi ulnaris (FCU), without superimposed cervical radiculopathy or other focal entrapment neuropathy. During open ulnar nerve neurolysis, an intramuscular lipoma was encountered within the FCU. Lipoma excision and cubital tunnel release with ulnar nerve transposition were performed with complete relief of neuropraxia. CONCLUSION: We demonstrate full neurologic recovery after intramuscular lipoma excision and cubital tunnel release. Although rare, anomalous anatomy and tissue overgrowth should remain on the differential for patients presenting with atypical neuropraxia.

Venous Thromboembolism after Deep Inferior Epigastric Perforator Flap Breast Reconstruction: Review of Outcomes After a Postoperative Prophylaxis Protocol.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flap breast reconstruction is among the higher-risk patient groups for venous thromboembolism (VTE) in plastic surgery. Surgeons often opt for a patient-specific approach to postoperative anticoagulation, and the field has yet to come to a consensus on VTE chemoprophylaxis regimens. METHODS: A new chemoprophylaxis protocol was introduced starting March 2019 that involved two weeks of treatment with enoxaparin, regardless of patient risk factors. A retrospective chart review was conducted on all patients who underwent DIEP flap breast reconstruction at our institution between January 2014 and March 2020. Patients were grouped based on whether they enrolled in the new VTE protocol in the postoperative period or not. Patient demographics, prophylaxis type, and outcomes data were recorded, retrospectively. The primary outcome measure was postoperative VTE incidence. RESULTS: Risk of VTE was significantly higher in patients discharged without VTE prophylaxis compared to patients discharged with prophylaxis (3.7% vs. 0%, p = 0.03). Notably, zero patients in the VTE prophylaxis group developed a DVT or PE. Additionally, the risk of a VTE event was 25 times greater in patients with a Caprini score greater than or equal to 6 (p=0.0002). CONCLUSIONS: We demonstrate the successful implementation of a two-week VTE chemoprophylaxis protocol in DIEP flap breast reconstruction patients that significantly reduces the rate of VTE while not affecting the rate of hematoma complications.

Plastic Surgery Training: Trends in Hand Surgery Fellowship in the Setting of a Pandemic.

Given the diminishing presence of hand surgeons trained in plastic surgery, we evaluated the associated trends in annual hand meeting educational content and postgraduate job offerings, and analyzed the effect of the coronavirus disease 2019 (COVID-19) pandemic on trainees in hand surgery. Methods: Hand meeting registration and educational content were analyzed over the past 10 years. Current hand surgery job offerings were evaluated for training requirements, and the annual rates of subspecialty certificate in surgery of the hand board certifications were compared across training backgrounds. Results: Top categories of annual meeting educational content were "bone/joint," "other," and "professional development." A majority of American Society for Surgery of the Hand presidents had training backgrounds in orthopedics (55%), followed by plastics (23%) and general surgery (22%). The job offerings on the American Society for Surgery of the Hand and Association for Surgery of the Hand websites specified more training requirements in orthopedics than in plastics. Additionally, there were two to three times as many examinees taking the surgery of the hand examination from orthopedic surgery compared with plastics, with an overall higher pass rate. Hand fellowship programs were also predominantly offered for orthopedic surgery (80.8%). Conclusions: Optimization of training, society membership, and clinical practice profiles may increase the presence of plastic surgery-trained hand surgeons. The extent of the economic impact of the COVID-19 pandemic is yet to be fully determined, but our analysis suggests that a lucrative market for reconstructive/hand surgery may exist in the face of economic downturn.

A Rare Case of Traumatic Acute Pronator Syndrome in the Setting of Anticoagulation Therapy.

Pronator syndrome (PS) is a rare type of peripheral compression neuropathy in which the median nerve becomes entrapped as it passes through the pronator teres muscle at the proximal forearm. We report an unusual case of acute PS in a 78-year-old patient on warfarin who presented after traumatic forearm injury with forearm swelling, pain, and paresthesias. After emergent nerve decompression and hematoma evacuation, the patient regained near complete recovery of median nerve function six months after diagnosis and treatment.

Extended Venous Thromboembolism Chemoprophylaxis following Microsurgical Breast Reconstruction: Analysis of Trends in Postoperative Anticoagulation.

BACKGROUND: Microsurgical breast reconstruction following mastectomy represents a high-risk patient group for venous thromboembolism (VTE), but there is limited consensus on postoperative prophylaxis duration. The aim of this study was to characterize the risk of VTE after microsurgical breast reconstruction, the risk reduction associated with postoperative outpatient VTE prophylaxis, the clinical factors associated with VTE events, and surgeon prescribing patterns regarding outpatient VTE prophylaxis. METHODS: A commercially available database of 53 million unique patients, PearlDiver, was used to identify patients with breast cancer who underwent microsurgical breast reconstruction. Patients were grouped into those receiving any form of outpatient VTE prophylaxis at discharge and those who did not. Probability of VTE within 90 days was calculated for each group followed by absolute risk reduction and number needed to treat. A logistic regression, assuming binomial distribution, was performed to determine clinical factors associated with VTE events after surgery. RESULTS: A total of 22,606 patients underwent microsurgical breast reconstruction from 2010 to 2020. Of these patients, 356 (1.6%) were discharged with VTE prophylaxis and 22,250 (98.4%) were discharged without. No patients developed a VTE in the prophylaxis group, and 403 (1.8%) developed a VTE in the group without prophylaxis. The number needed to prevent one VTE was 55.25 patients. Most VTE events occurred after postoperative day 10 (71.3%). CONCLUSIONS: Outpatient chemoprophylaxis following breast reconstruction is underused despite the majority of VTE events occurring after the acute postoperative period. Breast microsurgeons should consider routine outpatient chemoprophylaxis as part of their postoperative care pathway to optimize VTE prevention. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Breast Reconstruction Trends in the Setting of Postmastectomy Radiation Therapy: Analysis of Practices among Plastic Surgeons in the United States.

Radiation is an integral part of breast cancer therapy. The ideal type and timing of breast reconstruction with relation to radiation delivery are not well established. The study aimed to identify reconstructive practices among American plastic surgeons in the setting of pre- and postmastectomy radiation. Methods: A cross-sectional survey of members of the American Society of Plastic Surgery was performed. Practice/demographic information and breast reconstruction protocols were queried. Univariate descriptive statistics were calculated, and outcomes were compared across cohorts with χ2 and Fischer exact tests. Results: Overall, 477 plastic surgeons averaging 16.3 years in practice were surveyed. With respect to types of reconstruction, all options were well represented, although nearly 60% preferred autologous reconstruction with prior radiation and 55% preferred tissue expansion followed by implant/autologous reconstruction in the setting of unknown postoperative radiation. There was little consensus on the optimal timing of reconstruction in the setting of possible postoperative radiation. Most respondents wait 4-6 or 7-12 months between the end of radiation and stage 2 implant-based or autologous reconstruction. Common concerns regarding the effect of radiation on reconstructive outcomes included mastectomy flap necrosis, wound dehiscence, capsular contracture, tissue fibrosis, and donor vessel complications. Conclusions: Despite considerable research, there is little consensus on the ideal type and timing of reconstruction in the setting of pre- and postoperative radiation. Understanding how the current body of knowledge is translated into clinical practice by different populations of surgeons allows us to forge a path forward toward more robust, evidence-based guidelines for patient care.

Multidisciplinary Treatment of Persistent Nontuberculous Mycobacterial Spinal Hardware Infection with a Pedicled Superior Gluteal Artery Perforator Flap.

Nontuberculous mycobacterial hardware infections are extremely challenging to treat. Multidisciplinary care involving removal of infected hardware, thorough debridement, and durable soft tissue coverage in conjunction with antibiotic therapy is essential for successful management. This case report presents a patient with chronic mycobacterial spinal hardware infection that underwent successful treatment with aggressive serial debridements and reconstruction with a large pedicled superior gluteal artery perforator flap coverage.

Ulnar two-point discrimination following endoscopic carpal tunnel release.

Carpal tunnel syndrome is median nerve symptomatic compression at the level of the wrist, characterized by increased pressure within the carpal tunnel and decreased nerve function at the level. Carpal tunnel release decreases pressure in Guyon's canal, via open techniques, with symptom and two-point discrimination improvement in the ulnar nerve distribution. We hypothesize that endoscopic carpal tunnel release improves two-point discrimination in the ulnar nerve distribution as well. This study includes 143 patients who underwent endoscopic carpal tunnel release between April 2016 to June 2019 in a single, community-based teaching hospital. A comprehensive retrospective chart review was performed on patient demographics, pre- and post-operative two-point discrimination test results, and complications. The effects of sex, age, and diabetes mellitus in the ulnar and median nerve territories with two-point discrimination tests were analyzed. As well as the differences in two-point discrimination among patient's based on their smoking status. There were significant post operative improvements in both the median (7.7 vs 4.4 mm, p < 0.001) and ulnar (5.7 vs 4.1 mm, p < 0.001) nerve territories. Smoking status, sex, age and diabetes did not significantly affect two-point discrimination outcomes. In conclusion the endoscopic release of the transverse carpal ligament decompresses the carpal tunnel and Guyon's canal, demonstrating improvement in two-point discrimination in both the ulnar and median nerve distributions.

El síndrome de túnel carpiano es la compresión sintomática del nervio mediano al nivel de la muñeca. Se caracteriza por un aumento de presión dentro del túnel y una disminución de la función del nervio a ese nivel. La liberación del túnel carpiano descomprime el canal de Guyon, con mejoría sintomática y en la prueba de discriminación de dos puntos en la distribución del nervio cubital. Hipotetizamos que la liberación endoscópica mejora de la misma manera en la distribución del nervio cubital. Este trabajo incluye 143 pacientes que tuvieron liberación endoscópica del túnel carpiano entre abril del 2016 y junio del 2019 en un hospital Universitario de la comunidad. Se evaluaron retrospectivamente las historias clínicas para los datos demográficos, los resultados pre y post quirúrgicos en la prueba de discriminación de dos puntos y complicaciones. Se analizaron los efectos del sexo, edad, tabaco y diabetes en los resultados de la prueba de discriminación de dos puntos para los nervios cubital y mediano. Hubo mejoría significativa post quirúrgica en la prueba de discriminación de dos puntos para los nervios mediano (7.7 vs 4.4 mm, p < 0.001) y cubital (5.7 vs 4.1 mm, p < 0.001). Fumadores, sexo, edad, y diabetes no afectaron de forma significativa. Concluimos que la liberación endoscópica del ligamento transverso del carpo descomprime el túnel carpiano y el canal de Guyon con mejoría en la prueba de discriminación de dos puntos para los nervios cubital y mediano.

Ulnar two-point discrimination following endoscopic carpal tunnel release / La liberación endoscópica del túnel carpiano y la prueba de discriminación de dos puntos del nervio cubital

Abstract Carpal tunnel syndrome is median nerve symptomatic compression at the level of the wrist, characterized by increased pressure within the carpal tunnel and decreased nerve function at the level. Carpal tunnel release decreases pressure in Guyon's canal, via open techniques, with symptom and two-point discrimination improvement in the ulnar nerve distribution. We hypothesize that endoscopic carpal tunnel release improves two-point discrimination in the ulnar nerve distribution as well. This study includes 143 patients who underwent endoscopic carpal tunnel release between April 2016 to June 2019 in a single, community-based teaching hospital. A comprehensive retrospective chart review was performed on patient demographics, preand post-operative two-point discrimination test results, and complications. The effects of sex, age, and diabetes mellitus in the ulnar and median nerve territories with two-point discrimination tests were analyzed. As well as the differences in two-point discrimination among patient's based on their smoking status. There were significant post operative improvements in both the median (7.7 vs 4.4 mm, p < 0.001) and ulnar (5.7 vs 4.1 mm, p < 0.001) nerve territories. Smoking status, sex, age and diabetes did not significantly affect two-point discrimination outcomes. In conclusion the endoscopic release of the transverse carpal ligament decompresses the carpal tunnel and Guyon's canal, demonstrating improvement in two-point discrimination in both the ulnar and median nerve distributions.

Resumen El síndrome de túnel carpiano es la compresión sintomática del nervio mediano al nivel de la muñeca. Se caracteriza por un aumento de presión dentro del túnel y una disminución de la función del nervio a ese nivel. La liberación del túnel carpiano descomprime el canal de Guyon, con mejoría sintomática y en la prueba de discriminación de dos puntos en la distribución del nervio cubital. Hipotetizamos que la liberación endoscópica mejora de la misma manera en la distribución del nervio cubital. Este trabajo incluye 143 pacientes que tuvieron liberación endoscópica del túnel carpiano entre abril del 2016 y junio del 2019 en un hospital Universitario de la comunidad. Se evaluaron retrospectivamente las historias clínicas para los datos demográficos, los resultados pre y post quirúrgicos en la prueba de discriminación de dos puntos y complicaciones. Se analizaron los efectos del sexo, edad, tabaco y diabetes en los resultados de la prueba de discriminación de dos puntos para los nervios cubital y mediano. Hubo mejoría significativa post quirúrgica en la prueba de discriminación de dos puntos para los nervios mediano (7.7 vs 4.4 mm, p < 0.001) y cubital (5.7 vs 4.1 mm, p < 0.001). Fumadores, sexo, edad, y diabetes no afectaron de forma significativa. Concluimos que la liberación endoscópica del ligamento transverso del carpo descomprime el túnel carpiano y el canal de Guyon con mejoría en la prueba de discriminación de dos puntos para los nervios cubital y mediano.

Tobacco use and neurogenesis: A theoretical review of pathophysiological mechanism affecting the outcome of peripheral nerve regeneration.

Peripheral nerve injury often requires medical intervention. Unfortunately, many patients never have a full recovery, despite a multi-disciplinary approach, including operative intervention and physical and/or occupational therapy. Outcomes are multifactorial, but are largely affected by the original injury severity, and patient comorbidities. A lcoholism, diabetes mellitus and ageing may detrimentally affect the outcomes of nerve injury; however little is known about tobacco's potential impact on nerve regeneration. Tobacco has known immunomodulatory effects, which suggests that it might affect peripheral nerve regeneration and functional recovery following injury. This review characterizes the effects of tobacco use on the complex cellular and chemokine interactions in peripheral nerve regeneration.