Limb Salvage Using Microsurgical Free Tissue Transfer in Severe Frostbite.

PURPOSE: Frostbite is often managed conservatively; however, in severe cases, microsurgical free tissue transfer is required for soft tissue coverage and limb salvage. Given its rarity, the techniques and outcomes of these cases are not well described. The purpose of this report is to present the largest case series, to date, of frostbite injuries requiring microsurgical reconstruction for limb salvage. METHODS: A single-center retrospective review was conducted of all patients who underwent free tissue transfer by a single surgeon from 2008 to 2022. Patients of all ages were included if they suffered a frostbite injury requiring free tissue transfer. Demographics, operative details, and surgical outcomes were recorded. RESULTS: Eight patients with frostbite injuries were included in the report. Patients had frostbite injuries either to the lower extremities (n = 4) or to both upper and lower extremities (n = 4). Sixteen free flaps were done in total including four paired chimeric and eight single free flaps. Flap recipient sites included knees (n = 5), foot/ankle (n = 3), dorsal hands (n = 2), and thumbs (n = 2). All 16 flaps survived. Five patients had complications: four with major complications requiring operative management and two with minor complications requiring conservative management. Mean follow-up time was 505.7 days (range 115-1564). All lower extremity reconstructions were able to weight-bear at an average of 125.2 days post-injury (range 87-164). CONCLUSIONS: This case series demonstrates that free tissue transfer is a robust option for soft tissue coverage and functional limb salvage in patients with severe frostbite injuries to both upper and lower extremities.

Assessing the accuracy of algorithm-derived cardiorespiratory fitness in surgical patients: a prospective cohort study.

PURPOSE: To determine if a non-exercise algorithm-derived assessment of cardiorespiratory fitness (CRFA) accurately predicted estimated values obtained using a six-minute walk test (CRF6MWD) and the Duke Activity Status Index (CRFDASI). METHODS: Following research ethics board approval, an observational cohort study was conducted in selected, consenting patients undergoing elective surgery. Participants completed questionnaires assessing their self-reported exercise capacity. Their height, weight, waist circumference, and vital signs were measured. A six-minute walk test was performed twice with a 45-min rest interval between tests. The correlation between CRFA and both CRF6MWD and CRFDASI was determined. RESULTS: Two hundred forty-two participants were included. Mean age was 62 (range 45-88 yr); 150 (62%) were male, 87 (36%) self-reported walking or jogging > 16 km per week, and 49 (20%) were current smokers. The CRFA and CRF6MWD were highly correlated (Pearson r = 0.878; P < 0.001). CRFA and CRFDASI were less strongly correlated (Pearson r = 0.252; P < 0.001). Among patients capable of walking > 427 m in the six-minute walk test, CRFA, CRF6MWD, and CRFDASI were equivalent. CONCLUSION: A non-exercise algorithm can estimate cardiorespiratory fitness in patients presenting for elective surgery. The variables required to compute CRFA can be obtained in a clinic setting without the need to engage in formal exercise testing. Further evaluation of CRFA as a predictor of long-term outcome in patients is warranted.

Anterior Interosseous-to-Ulnar Motor Nerve Transfers: A Single Center's Experience in Restoring Intrinsic Hand Function.

Background: Transfer of the anterior interosseous nerve (AIN) into the ulnar motor branch improves intrinsic hand function in patients with high ulnar nerve injuries. We report our outcomes of this nerve transfer and hypothesize that any improvement in intrinsic hand function is beneficial to patients. Methods: A retrospective review of all AIN-to-ulnar motor nerve transfers, including both supercharged end-to-side (SETS) and end-to-end (ETE) transfers, from 2011 to 2018 performed by 2 surgeons was conducted. All adult patients who underwent this nerve transfer for any reason with greater than 6 months' follow-up and completed charts were included. Primary outcome measures were motor function using the British Medical Research Council (BMRC) grading system and subjective satisfaction with surgery using a visual analog scale. Secondary outcome measures included complications and donor site deficits. Results: Of the 57 patients who underwent nerve transfer, 32 patients met the inclusion criteria. The average follow-up and average time to surgery were 12 and 15.6 months, respectively. The overall average BMRC score was 2.9/5, with a trend toward better recovery in patients who received earlier surgery (<12 months = BMRC 3.7, ≥12 months = BMRC 2.2; P < .01). Patients with an SETS transfer had better results that those with an ETE transfer (SETS = 3.2, ETE = 2.6). There were no donor deficits after operation. One patient developed complex regional pain syndrome. Conclusions: Patients with earlier surgery and an in-continuity nerve (receiving an SETS transfer) showed improved recovery with a higher BMRC grade compared with those who underwent later surgery. Any improvements in intrinsic hand function would be beneficial to patients.

Surgeon-administered Ultrasound-guided Peripheral Nerve Blocks in Outpatient Procedures of the Upper Extremity.

Outpatient hand surgery is often performed in the operating room, which can result in prolonged waiting times for patients when operating room resources are limited. Few studies have explored the application of ultrasound-guided nerve blocks in the setting of outpatient hand surgery. Fifty patients were enrolled in this prospective study. Ultrasound-guided peripheral nerve blocks were performed at the level of the elbow and proximal forearm for outpatient hand surgeries. A timer was used to record the time to administer the block and time to affect. A post-procedure survey was administered, which included a numerical analogue scale (0-10) and Likert rating scale questions to characterize the patients' pain experience for receiving the block and pain during the procedure: pain experienced by patients receiving the ultrasound-guided nerve block(s) (0-10), mean: 1.84; pain experienced by patients during a procedure (0-10), mean: 0.56; surgeon satisfaction during the procedure (0-10), mean 9.78. Average time to perform the ultrasound-guided nerve block(s) was 4 minutes 58 seconds; average time from completion of the block to effect reported by patients, 5 minutes 42 seconds; the average time for performing the procedure, 21 minutes 30 seconds. Our study shows that the use of ultrasound to block peripheral nerves of the forearm is effective; <10% of patients required additional local anesthetic. The technique is safe; no complications were reported. The technique is efficient in an outpatient hand surgery setting.

Sexual Harassment of Canadian Medical Students: A National Survey.

BACKGROUND: Despite explicit policies and reporting mechanisms in academia designed to prevent harassment and ensure respectful environments, sexual harassment persists. We report on a national survey of Canadian medical students' experiences of sexual harassment perpetrated by faculty, patients and peers, their responses to harassment, and their suggestions for improving the learning environment. METHODS: With ethics approval from all 17 Canadian universities with medical schools, an invitation to participate in an anonymous, electronic survey was included in three Canadian Federation of Medical Students' newsletters (2016). Narrative information about sexual harassment during medical training, perpetrators, ways of coping, sources of support, formal and informal reporting/discussion, and suggestions for change was sought. Three authors then conducted a qualitative analysis and identified emergent themes. FINDINGS: When asked to estimate the number of occurrences of SH experienced during medical school, 188 students reported 807 incidents perpetrated by peers, patients, and, to a lesser extent, faculty. Perpetrators were almost always men and 98% of victims were women. What emerged was a picture of social, educational, and individual conditions under which sexual harassment becomes normalised by faculty, peers and victims. Students often tried to ignore harassment despite finding it confusing, upsetting, and embarrassing. They offered strategies for schools to raise awareness, support students, and prevent or mitigate harms going forward. INTERPRETATION: Sexual harassment is a part of the Canadian medical education environment where most who reported harassment are subject to the dual vulnerabilities of being learners and women. Although survey respondents recognised the systemic nature of the problem, as individuals they often described shame and self-blame when victimised, came up with solutions that implied they were the problem, and often reported thinking silence was less risky than confrontation or official reporting. Many participants believed in the transformative power of education - of themselves and faculty - as a means of improving the medical environment whilst we await social change.