Efficacy of Intra-Articular Corticosteroid Injection for Nonsurgical Management of Trapeziometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: As osteoarthritis (OA) of the trapeziometacarpal (TMC) joint leads to a high degree of disease burden with compromises in rudimentary and fine movements of the hand, intra-articular injections may be a desirable treatment option. However, because there are no evidence-based guidelines, the choice of intra-articular injection type is left to the discretion of the individual surgeon in collaboration with the patient. The purpose of our study was to perform a systematic review and meta-analysis using level I studies to compare outcomes following corticosteroid and alternative methods of intra-articular injections for the management of TMC OA. Our hypothesis was that intra-articular corticosteroid injections were no more effective than other methods of intra-articular injections for the management of TMC OA. METHODS: A systematic literature search was performed. Eligible for inclusion were randomized control trials reporting on intra-articular corticosteroid injection for the management of TMC OA. Clinical outcomes were recorded. RESULTS: The 10 included studies comprised 673 patients. The mean age was 57.8 ± 8.3 years, with a mean follow-up of 6.4 ± 2.7 months. There was no significant difference in visual analog scale scores, grip strength and tip pinch strength between corticosteroids and hyaluronic acid at short- and medium-term follow-up. Further, there was no difference in visual analog scale pain scores at rest at medium-term follow-up between corticosteroids and platelet-rich plasma. CONCLUSIONS: Despite short-term improvement with intra-articular corticosteroid injections, there was no significant difference in pain and functional outcomes following intra-articular corticosteroid injections compared to hyaluronic acid or platelet-rich plasma administration. Given the affordability, ease of administration, and efficacy associated with corticosteroids, they are a favorable option when considering the choice of intra-articular injection for the management of TMC OA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Cryoanalgesia: Review with Respect to Peripheral Nerve.

BACKGROUND: Cryoanalgesia is a tool being used by interventional radiology to treat chronic pain. Within a certain cold temperature range, peripheral nerve function is interrupted and recovers, without neuroma formation. Cryoanalgesia has most often been applied to the intercostal nerve. Cryoanalgesia has applications to peripheral nerve surgery, yet is poorly understood by reconstructive microsurgeons. METHODS: Histopathology of nerve injury was reviewed to understand cold applied to peripheral nerve. Literature review was performed utilizing the PubMed and MEDLINE databases to identify comparative studies of the efficacy of intraoperative cryoanalgesia versus thoracic epidural anesthesia following thoracotomy. Data were analyzed using Fisher's exact and analysis of variance tests. A similar approach was used for pudendal cryoanalgesia. RESULTS: Application of inclusion and exclusion criteria resulted in 16 comparative clinical studies of intercostal nerve for this review. For thoracotomy, nine studies compared cryoanalgesia with pharmaceutical analgesia, with seven demonstrating significant reduction in postoperative opioid use or postoperative acute pain scores. In these nine studies, there was no association between the number of nerves treated and the reduction in acute postoperative pain. One study compared cryoanalgesia with local anesthetic and demonstrated a significant reduction in acute pain with cryoanalgesia. Three studies compared cryoanalgesia with epidural analgesia and demonstrated no significant difference in postoperative pain or postoperative opioid use. Interventional radiology targets pudendal nerves using computed tomography imaging with positive outcomes for the patient with pain of pudendal nerve origin. CONCLUSION: Cryoanalgesia is a term used for the treatment of peripheral nerve problems that would benefit from a proverbial reset of peripheral nerve function. It does not ablate the nerve. Intraoperative cryoanalgesia to intercostal nerves is a safe and effective means of postoperative analgesia following thoracotomy. For pudendal nerve injury, where an intrapelvic surgical approach may be difficult, cryoanalgesia may provide sufficient clinical relief, thereby preserving pudendal nerve function.

Complications Following Volar Locking Plate Fixation of Distal Radius Fractures in Adults: A Systematic Review of Randomized Control Trials.

PURPOSE: The purpose of this study was to assess the incidence of postoperative complications following volar locking plate (VLP) fixation of distal radius fractures (DRFs). METHODS: A search using keywords and subject headings to represent the concepts of volar plating and radius fractures was generated. Databases such as MEDLINE (Ovid), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCO) were searched from inception to November 24, 2021, for randomized controlled trials that reported complications following DRF treated with VLP. Inclusion criteria were studies with adult patients (aged ≥18 years) randomized to VLP fixation without other concomitant surgical interventions, with a minimum follow-up of 3 months. Study sample characteristics and post-surgical complications were extracted. The Cochrane Risk of Bias tool was used to evaluate quality of evidence. RESULTS: Of the 4,059 articles identified using the search strategy, 1,778 titles/abstracts and 856 full-text articles were screened for inclusion, of which 35 articles were included for data extraction. Overall, 1,419 patients with a DRF were randomized to VLP fixation. The mean age was 60.3 years. The overall complication rate was 30.8% following VLP fixation, with 12.4% being major complications. The most common complications were median nerve-related (7.1%) and hardware removal (6.8%), secondary to other complications. Tenosynovitis was the most common tendon-related complication (3.4%). Other complications included complex regional pain syndrome (2.4%), malunion (1.3%), superficial wound infections (1.9%), and tendon rupture (1.3%). CONCLUSIONS: A meta-analysis of high-quality studies that discuss the complications after VLP fixation for DRF showed an overall complication rate of 30.8%. VLP may be related to more hardware-related complications than those previously reported. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Microvascular free tissue transfer for reconstruction of complex lower extremity trauma: Predictors of complications and flap failure.

BACKGROUND: Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population. METHODS: Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002-2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed. RESULTS: One hundred eighty-eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap-failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure. CONCLUSIONS: When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.

Platelet-rich plasma vs. corticosteroid injections for the treatment of recalcitrant lateral epicondylitis: a cost-effectiveness Markov decision analysis.

BACKGROUND: Both platelet-rich plasma (PRP) and corticosteroid injections may be used to treat lateral epicondylitis. We evaluated the cost-effectiveness of PRP injections vs. corticosteroid injections for the treatment of recalcitrant lateral epicondylitis. METHODS: Markov modeling was used to analyze the base-case 45-year-old patient with recalcitrant lateral epicondylitis, unresponsive to conservative measures, treated with a single injection of PRP or triamcinolone 40 mg/mL. Transition probabilities were derived from randomized controlled trials, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry reported using Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and costs from institution financial records. Analyses were performed from health care and societal perspectives. Outcomes were incremental cost-effectiveness ratios (ICERs), reported as US dollars / quality-adjusted life-year (USDs/QALY) and net monetary benefit (NMB) to represent the values of an intervention in monetary terms. Willingness-to-pay thresholds were set at $50,000 and $100,000. Deterministic and probabilistic sensitivity analyses were performed over 10,000 iterations. RESULTS: Both PRP and triamcinolone 40-mg/mL injections were considered cost-effective interventions from a health care and societal perspective below the WTP threshold of $50,000. From a health care perspective, PRP injections were dominant compared with triamcinolone 40-mg/mL injections, with an ICER of -$5846.97/QALY. PRP injections provided an NMB of $217,863.98, whereas triamcinolone 40 mg/mL provided an NMB of $197,534.18. From a societal perspective, PRP injections were dominant compared to triamcinolone 40-mg/mL injections, with an ICER of -$9392.33/QALY. PRP injections provided an NMB of $214,820.16, whereas triamcinolone 40 mg/mL provided an NMB of $193,199.75. CONCLUSIONS: Both PRP and triamcinolone 40-mg/mL injections provided cost-effective treatments from health care and societal perspectives. Overall, PRP injections were the dominant treatment, with the greatest NMB for recalcitrant lateral epicondylitis over the time horizon of 5 years.

Comparison of nine methods of immediate breast reconstruction after resection of localized breast cancer: A cost-effectiveness Markov decision analysis of prospective studies.

BACKGROUND: Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer. METHODS: Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000. RESULTS: From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84. CONCLUSIONS: All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.

Predictors of Plastic Surgeons Becoming Presidents of National Professional Organizations in the United States of America.

BACKGROUND: We evaluated metrics between academic plastic surgeons that were and were not presidents of national organizations to determine predictors of becoming a president. METHODS: A cross-sectional retrospective review was performed. Websites were queried of 99 Accreditation Council for Graduate Medical Education accredited plastic surgery residency programs and 17 national organizations. Demographic, academic and scholarly variables we collected from 951 full-time plastic surgery faculty affiliated with the US residency training programs during the 2020-2021 academic year. Of these full-time plastic surgery faculty, 879 were non-presidents and 72 were presidents of national organizations (2016-2021 = 42, < 2016 = 30). RESULTS: Plastic surgeons were more likely to become president if they were an officer/director of the American Board of Plastic Surgeons (ABPS) (OR: 16.67, 95%CI: 5.83, 47.66; p < 0.001), chief/chair of a division/department (OR: 3.10, 95%CI: 1.09, 8.79; p = 0.033), endowed (OR: 5.45, 95%CI:1.65, 18.04; p = 0.006), National Institutes of Health (NIH) funded (OR: 4.57, 95%CI: 1.24, 16.88; p = 0.023), affiliated with an integrated plastic surgery residency program (OR: 3.96, 95%CI: 1.27, 12.33; p = 0.018), and with a greater number of years in practice (OR: 1.09, 95%CI: 1.04, 1.14; p < 0.001). Additionally, plastic surgeons were more likely to become president between 2016 and 2021 with a research fellowship (OR: 7.41, 95%CI: 1.02, 52.63; p = 0.047), first author publications (OR: 1.72, 95%CI: 1.63, 1.83; p < 0.001), and last author publications (OR: 1.60, 95%CI: 1.56, 1.65; p < 0.001). CONCLUSIONS: Plastic surgeons were more likely to become president of a national organization if they were an officer/director of the ABPS, chief/chair of a division/department, endowed, NIH funded, affiliated with an integrated plastic surgery residency program, greater number of years in practice, research fellowship, and first and last author publications. Predictors may guide those interested in becoming president of a national organization. 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery.

BACKGROUND: Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications. OBJECTIVES: To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery. SEARCH METHODS: The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials. SELECTION CRITERIA: We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes. MAIN RESULTS: We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I2 = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I2 = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I2 = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I2 = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I2 = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I2 = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I2 = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I2 = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I2 = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.

Surgical Debulking for Symptomatic Management of Calcinosis Cutis of the Hand and Upper Extremity in Systemic Sclerosis.

PURPOSE: To determine whether elective calcinosis debulking surgery of the hands and/or upper extremities is a safe and effective treatment for painful symptomatic scleroderma. Our hypothesis was that calcinosis debulking surgery would result in improvement in patient-reported pain and range of motion (ROM) with relatively little postoperative surgical pain for scleroderma patients. METHODS: We performed a retrospective review of scleroderma patients who underwent elective calcinosis debulking surgery by a single surgeon between August 2014 and August 2019. Patients were included if they had a documented diagnosis of limited or diffuse scleroderma and underwent elective or nonemergent hand or upper-extremity calcinosis debulking surgery with a minimum final follow-up of 12 months. Primary outcomes measured were preoperative to final follow-up changes in visual analog scale pain scores. Secondary outcomes were changes in numbness and ROM as well as in daily opioid requirements, postoperative opioids used to control surgical pain, and complications. RESULTS: Thirty-nine patients underwent calcinosis debulking surgeries on 41 upper extremities. Median final follow-up was 22 months (range, 13-60 months). Significant decreases occurred in visual analog pain scores (preoperative median, 5 [range, 0-10); final follow-up median, 0 [range, 0-8]) and improved patient-reported ROM in 15% (no change, 85%; worse, 0%). There was no significant preoperative to final follow-up difference in patient-reported numbness (improved, 5%; no change, 85%; and worse, 10%). Thirteen patients incurred 17 complications. CONCLUSIONS: Elective calcinosis debulking surgery of the hands and/or upper extremities in scleroderma decreased pain scores, improved patient-reported ROM in 15% of patients, and had no effect on patient-reported numbness at final follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Chronic Neuropathic Pain Following Hand Burns: Etiology, Treatment, and Long-Term Outcomes.

PURPOSE: Chronic neuropathic pain (CNP) after burn injury to the hand/upper extremity is relatively common, but not well described in the literature. This study characterizes patients with CNP after hand/upper extremity burns to help guide risk stratification and treatment strategies. We hypothesize that multiple risk factors contribute to the development of CNP and refractory responses to treatment. METHODS: Patients older than 15 years admitted to the burn center after hand/upper extremity burns, from January 1, 2014, through January 1, 2019, were included. Chronic neuropathic pain was defined as self-described pain for longer than 6 months after burn injury, not including pain due to preexisting illness/medications. Two analyses were undertaken: (1) determining risk factors for developing CNP among patients with hand/upper extremity burns, and (2) determining risk factors for developing refractory pain (ie, nonresponsive to treatment) among hand/upper extremity burn patients with CNP. RESULTS: Of the 914 patients who met the inclusion criteria, 55 (6%) developed CNP after hand/upper extremity burns. Twenty-nine of these patients (53%) had refractory CNP. Significant risk factors for developing CNP after hand/upper extremity burns included history of substance abuse and tobacco use. Among CNP patients, significant risk factors for developing refractory pain included symptoms of burning sensations. In all CNP patients, gabapentin and ascorbic acid were associated with significant decreases in pain scores on follow-up. CONCLUSIONS: Substance abuse and tobacco use may contribute to the development of CNP after hand/upper extremity burns. Those who developed refractory CNP were more likely to use the pain descriptor, burning sensations. Pharmacological pain management with gabapentin or pregabalin and ascorbic acid may provide the most relief of CNP symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcomes Associated With Scapholunate Ligament Injury Following Intra-Articular Distal Radius Fractures.

PURPOSE: The purpose of this study was to evaluate a series of intra-articular distal radius fractures (DRFs) to determine whether patients without radiographic evidence of scapholunate (SL) ligament injury have a difference in outcomes in comparison with patients with radiographic evidence of SL ligament injury and no ligament repair or reconstruction. Our hypothesis is that there are no significant differences in outcomes between patients after treatment of their intra-articular DRF. METHODS: A retrospective analysis of patients from a single institution who sustained an intra-articular DRF from January 2006 through January 2019 with minimum 12-month (n = 192) and 24-month (n = 100) follow-up was performed. Patient demographic, clinical, and outcome variables were compared between SL angles less than 70° (cohort 1) and SL angles 70° or greater (cohort 2). Radiographic parameters were measured and recorded at 3 time points: baseline in the contralateral wrist, following closed reduction but prior to surgical intervention, and at final follow-up. Outcomes collected included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Modified Global Assessment of Function (mGAF), and a visual analog scale (VAS) for pain. RESULTS: One hundred ninety-two patients were included. Of these 192 patients, cohort 1 (n = 110) was observed to have median (range) SL angles of 58° (42°-68°) and cohort 2 (n = 82) median (range) SL angles of 74.5° (70°-87°) after closed reduction. Cohort 2 had statistically significant increases in median SL angles from closed reduction to final follow-up (74.5° [range, 70°-87°) to 78.5° (range, 71°-107°). There were no statistically significant differences in QuickDASH disability scores, mGAF scores, and VAS pain scores between the cohorts at initial and final follow-ups. CONCLUSIONS: Patient-reported outcomes at 12 and 24 months do not differ between patients without radiographically apparent SL ligament injury (SL angles < 70°) and patients with radiographically apparent SL ligament injury(SL angles ≥ 70°) who do not undergo ligament repair or reconstruction following treatment of their intra-articular DRF. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Leaders of the Pack: A Comparison of Chairs and Chiefs to Other Surgeons in American Academic Plastic Surgery.

ABSTRACT: Chairs/chiefs of plastic surgery departments/divisions are responsible for directing activities at academic institutions and thus help determine the direction of academic plastic surgery. Other studies have characterized this group but have not shown which characteristics separate them from other surgeons in the field. To study this relationship, a cross-sectional analysis of plastic surgery faculty affiliated with United States residency training programs (n = 99) was initiated. Data were collected from public online websites. Univariate and multivariate logistic regression were used to identify factors independently associated with chairs/chief status. Sub-analyses were performed within Tiers stratified by residency program rank of chair/chief's current institution. Among 943 plastic surgeons, 98 chairs/chiefs were identified. In accordance with prior literature, most are male (89%) and fellowship-trained (62%), and they have a median H-index of 17. Compared to other surgeons, chair/chiefs have more years in practice (odds ratio [OR]: 1.026, confidence interval [CI]: 0.002-0.049, P = 0.034), higher H-index (OR: 1.103, CI: 0.048-0.147, P < 0.001), and more citations (OR: 1.000, CI: -0.000 to -0.001, P = 0.006). Chair/chiefs were also more likely to be journal editorial board members (OR: 1.728, CI: -0.033 to 1.127, P = 0.046) and national society/organization presidents (OR: 1.024, CI: 0.008-0.039, P = 0.003). No notable differences were found between department chairs versus division chiefs or across Tiers. Overall, scholarly achievement and significant years of experience distinguish chairs/chiefs in American academic plastic surgery. Criteria for achieving this leadership role may not differ between departments and divisions. Further research is needed to evaluate whether these characteristics translate into more effective leadership.

"A Sign of Things to Come: Training Research Output Long-Term Scholarship in Academic Plastic Surgery."

BACKGROUNDS: Academic plastic surgery has utilized different methods to promote early involvement of trainees in research. Further analysis is needed to characterize the effects of this early emphasis and their impact on long-term academic contributions to the field. METHODS: In October 2020, a cross-sectional study of 949 faculty from US academic plastic surgery programs was conducted using publicly available websites. Training research output for each surgeon was compared to post-training research output and other metrics measuring sustained career scholarship. RESULTS: Increased training publications (P< 0.0001) and citations (P< 0.0001) were associated with fewer years in practice. 727 surgeons (80.0%) had ≥ 1 research article, and this group proceeded to attain significantly higher mean post-training publications per year (3.04 ± 0.14 vs. 1.45 ± 0.13, P< 0.0001) and citations per year (72.12 ± 5.04 vs. 28.39 ± 3.49, P< 0.0001) compared to the 182 (20.0%) surgeons with no training publications. For individuals, total training publications were positively correlated with post-training publications per year (P< 0.0001), a relationship also observed for citations (P< 0.0001). When controlling for years in practice, increased training publications and/or citations were significantly associated with attaining academic professor track (versus clinical professor track) position, endowed professor status, journal board position, and NIH funding (P< 0.05 for all). CONCLUSIONS: There is a trend of increasing research productivity during plastic surgery training, and increased training output is predictive of attaining multiple measures of career academic achievement. Academic plastic surgery should continue to underscore research participation as a valuable part of the training process. 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 .

Neurolysis of the Dorsal Nerve to the Penis to Restore Function After Trauma.

BACKGROUND: Loss of penile sensation or development of a painful penis and erectile dysfunction can occur after injury to the dorsal branch of the pudendal nerve. Although recovery of genital sensibility has been discussed frequently in transmen, this subject has been reported rarely in cismen. The purpose of this report is to review our experience with recovery of sensation in men after decompression of the dorsal branch of the pudendal nerve after trauma. METHODS: A retrospective chart review of men who have had decompression of the dorsal branch of the pudendal nerve was carried out from 2014 to 2018. Patients were included in the cohort if they had a loss of penile sensation or the development of a painful penis after trauma. Primary outcomes measured were the change in penile symptoms, including erection, ejaculation, ejaculatory pain, erogenous sensation, numbness, and penile pain. RESULTS: For the 7 men included in this study, the mean follow-up time was 57 weeks (range, 28-85 weeks). Bilateral surgery was done in 71% (5/7). Of the 6 patients with loss of penile sensation, complete recovery of erogenous sensibility occurred in 5 (83%) patients, with partial relief in 1 (17%) patient. Of the 3 men who had erectile dysfunction, normal erections were restored in 2 (67%) patients. Of the 2 patients unable to ejaculate, 1 (50%) patient regained ejaculatory function. Of the 4 patients with ejaculatory pain, complete relief of pain occurred in 2 (50%) patients, with partial relief in 2 (50%) patients. Of the 6 patients with penile pain in the absence of ejaculation, complete relief of pain occurred in 3 (50%) patients, with partial relief in 3 (50%) patients. CONCLUSION: Neurolysis of the dorsal nerve to the penis at the inferior pubic ramus canal can be successful in relieving pain, and restoring sensation and erectile function in men who sustained an injury along the inferior pubic ramus.

Risk Factors Associated With the Progression From Acute to Chronic Neuropathic Pain After Burn-Related Injuries.

BACKGROUND: Pain, unrelated to the initial thermal trauma itself, can result after burn injury and prolong the recovery/rehabilitation phase of the patient's care. This pain, after discharge from the burn unit, may be acute and self-limiting or chronic and contribute to long-term patient morbidity. The purposes of this study were to compare burn patients who had, after discharge from the burn unit, only acute pain with burn patients who developed chronic, neuropathic pain (CNP) and to determine risks factors for progression from acute to chronic pain in the setting of a burn center. METHODS: A single-center, retrospective chart review of patients admitted to the adult burn center was performed from January 1, 2014, to January 1, 2019. Patients included were older than 15 years, sustained a burn injury, and admitted to the burn unit. Chronic pain was defined as pain lasting greater than 6 months after discharge from the burn unit. Pain descriptors included shooting, stabbing, sharp, burning, tingling, numbness, throbbing, pruritus, intermittent, and/or continuous dysesthetic sensations after the burn. Patients were excluded if they had preexisting neuropathic pain due to an underlying medical illness or previous surgery. RESULTS: During a 5-year period, of the 1880 admissions to the burn unit, 143 burn patients developed post-initial-onset pain as a direct result of their burn. Of the 143 patients with acute pain, pain resolved in 30 patients, whereas pain progressed to CNP in 113 patients (79%). Patient follow-up was a median (interquartile range [IQR]) of 26.5 (10-45) months. Patients whose pain progressed to CNP had significantly greater percent total body surface area burns (median [IQR], 6 [3-25] vs 3 [1-10]; P = 0.032), had more full-thickness burns (66/113 [58%] vs 8/30 [27%] patients, P = 0.004), had surgery (85/113 [75%] vs 16/30 [53%] patients, P = 0.042), had more surgical procedures (median [IQR], 2 [1-6] vs 1 [0-3], P = 0.002), and developed more complications (32/113 [28%] vs 2/30 [7%] patients, P = 0.014) compared with those with acute neuropathic pain, respectively. CONCLUSIONS: Burn patients who progressed from having acute to CNP had significantly greater percent total body surface area burns, had more full-thickness burns, had surgery, had more surgical procedures, and developed more complications compared with burn patients with only acute pain.

The Management of Perioperative Immunosuppressant Medications for Rheumatoid Arthritis During Elective Hand Surgery.

PURPOSE: Rheumatoid arthritis (RA) is a destructive inflammatory disease that commonly involves joints of the hand and wrist. Different recommendations exist for continuing or discontinuing immunosuppressant medications during the perioperative time period. The purpose of our study was to determine whether continuing or discontinuing medications (steroids, nonbiological, and/or biological disease-modifying antirheumatic drugs [DMARDs]) were associated with an increased or decreased risk of postoperative complications. METHODS: We performed a single-center, retrospective review of a cohort of RA patients who had elective hand surgery by a single surgeon. Patients were included if they had a documented diagnosis of seropositive RA by a rheumatologist and had elective hand surgery and/or a disease-related surgical procedure involving the upper extremity between January 2008 and August 2018. We stratified patients into different groups for comparison by classes of immunosuppressant medications for managing RA. These classes included corticosteroids, nonbiological DMARDs, biological DMARDs, and/or no medications. Immunosuppressant medications were then compared with no medications for the incidence of postoperative overall complications. RESULTS: Eighty-eight patients had elective hand and/or upper extremity surgeries for RA. Mean patient age at the time of surgery (± SD) was 55 ± 13 years (range, 24-74 years). Of these 88 patients, 8 (9%) overall complications occurred. Complications were wound healing failures (n = 5), tendon rupture (n = 1), hematoma (n = 1), and surgical-site infection (n = 1). Perioperative medications included steroids (n = 31), nonbiological DMARDs (n = 68), biological DMARDs (n = 5), and no medication (n = 27). There were no significant differences in overall complications between patients on immunosuppressant medications and those on no medications. Median (interquartile range) follow-up was 11.5 months (5-25.8) (range, 2-74 months). CONCLUSIONS: We found that patients who continued or discontinued medications within 1 dosing interval of their usual dose perioperatively had similar rates of complications following elective hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparison of arterial and venous implantable Doppler postoperative monitoring of free flaps: Systematic review and meta-analysis of diagnostic test accuracy.

BACKGROUND: Early detection of vascular compromise following free flap microsurgical reconstruction is essential. This can lead to timely reoperations and flap salvage. Both arteries and veins are monitored postoperatively with implantable ultrasound Dopplers based on surgeon preference with no consensus as to which method is best. This systematic review and meta-analysis compared arterial to venous implantable Dopplers for postoperative monitoring of microsurgical free flap reconstruction. METHODS: Five databases (MEDLINE via PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus) were systematically and independently searched. PRISMA and Cochrane guidelines were strictly followed. Clinical characteristics, donor and recipient sites, specific arterial or venous vessels, diagnostic data, outcomes, and complications were recorded. RESULTS: The seven studies included in the meta-analysis were published from 1994 to 2018, with results from 38 of the possible 64 outcomes and complications queried. A total of 763 flaps with implantable Doppler probes on 527 arteries and 388 veins were included in the study. Compared to patients monitored with venous implantable Dopplers, arterial monitoring was associated with a risk of false-positives reduced by 74% (RR:0.26, 95% CI:0.12, 0.55, I2 = 40%, p = .0004) and risk of signal loss reduced by 63% (RR:0.37, 95% CI:0.24, 0.59, I2 = 26%, p < .0001). Patients being monitored with a venous implantable Doppler did not show significantly different sensitivities, specificities, true-positives, false-negatives, true-negatives, positive predictive values, negative predictive values, time to signal loss, take-backs, salvage rates, flap failures, flap failure rates, arterial, venous, vascular, and hematoma compromise compared to an arterial implantable Doppler. CONCLUSION: These findings suggest arteries may be the best vessels to monitor when using an implantable Doppler following free flap microsurgical reconstruction. Caution is advised when interpreting these findings for clinical significance due to no significant differences in take-backs, SR, flap failures, and FFR.

Establishing Institution-Specific Normative Data for the BREAST-Q Reconstruction Module: A Prospective Study.

BACKGROUND: Breast satisfaction in general female populations is relatively unknown and prior research populations do not reflect our community. OBJECTIVES: We sought to assess breast satisfaction in a cohort of female participants utilizing the BREAST-Q and determine the impact of participant-related factors. METHODS: Females with no history of breast cancer or breast surgery attending gynecology appointments completed preoperative BREAST-Q reconstruction modules and demographic forms in this prospective, single-center, patient-reported outcomes study. We also assessed participant-related factors capable of influencing BREAST-Q scores. RESULTS: Three hundred females were included. Increasing body mass index had significant associations with lower Satisfaction with Breasts and Psychosocial Well-being scores. Increasing age was associated with significantly lower Sexual Well-being scores. African Americans had significantly higher scores for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being compared with Caucasians. Bra cup sizes A and C were associated with significantly higher Psychosocial Well-being scores than other sizes. Bra cup sizes A, B, and C were associated with significantly higher Sexual Well-being and Physical Well-being: Chest scores than larger sizes. Bra cup sizes B and C were associated with significantly higher Physical Well-being: Abdomen scores than size DD. Bra cup size A was associated with significantly higher Satisfaction with Breasts scores than sizes DD and >DD. Bra cup size C was associated with significantly higher Satisfaction with Breasts scores than larger sizes. CONCLUSIONS: Body mass index, age, race, and bra cup sizes significantly impact BREAST-Q scores in our population. Determining normative BREAST-Q scores in female populations could represent important baselines for breast outcomes research.Level of Evidence: 2.

Mary Edwards Walker (1832-1919): Approach to limb salvage therapy.

Mary Edwards Walker (1832-1919) was the first female surgeon in the United States. Her upbringing and unique medical training led her to practice medicine in a way that was revolutionary for the time. During the Civil War, her approach to wound care rivaled the current standard of care. During an era that predated antiseptic surgical technique, she prioritized cleanliness and hygiene. She opposed amputation for its surgical risks and decreased postoperative quality of life. She believed that many wounds, when appropriately attended to, would heal without amputation. She advocated for patients who she believed did not require amputations and counseled them on their rights to refuse surgical care.

Pain Management in Burn Patients: Pharmacologic Management of Acute and Chronic Pain.

Burn-related pain can contribute to decreased quality of life and long-term morbidity, limiting functional recovery. Burn-related pain should be assessed first by chronicity (acute or chronic), followed by type (nociceptive, neuropathic, nociplastic), to guide multimodal pharmacologic management in a stepwise algorithm approach. Combination therapies increase the efficacy and reduce toxicity by offering a multimodal approach that targets different receptors in the peripheral nervous system and central nervous system. When multimodal pharmacologic management is ineffective, etiologies of burn-related pain amenable to surgical interventions must be considered. It is important to know when to refer a patient to pain management.