Comparing Dermabond PRINEO versus Dermabond or staples for wound closure: a randomized control trial following total shoulder arthroplasty.

BACKGROUND: The method of surgical incision closure after total shoulder arthroplasty is an important factor to consider, as it affects operating room time, procedure cost, cosmetic outcomes, and patient satisfaction. The optimal method of wound management is unknown, but should be cost-effective, reproducible, and provide a reliable clinical result. This study aimed to compare the following wound closure methods after total shoulder arthroplasty: staples, Dermabond, and Dermabond PRINEO. We hypothesized that wound closure time for Dermabond PRINEO would be faster than Dermabond and comparable to that of staples, and Dermabond PRINEO would be more cost-effective than Dermabond and staples, and provide equal or superior closure outcomes to Dermabond and staples. METHODS: A randomized, prospective clinical trial comparing wound closure time and cost for 2 surgeons' traditional technique with that of Dermabond PRINEO was conducted. This study included at least 18 subjects in each group. Surgeon 1's patients were randomized to traditional Dermabond or Dermabond PRINEO, whereas surgeon 2's patients were randomized to staples or Dermabond PRINEO. Cosmetic outcomes and satisfaction scores were collected at 6 weeks and 3 months, postoperatively. Incisions were photographed, at both the 6-week and 3-month visits, and subsequently evaluated by a plastic surgeon blinded to the treatment method. RESULTS: The wound closure time for surgeon 1 was significantly faster for Dermabond PRINEO vs. Dermabond, and surgeon 2 closed significantly faster with staples vs. Dermabond PRINEO. The mean cost of closure was significantly less with Dermabond PRINEO compared with Dermabond, whereas the mean cost of staples was significantly less than Dermabond PRINEO. For both surgeons 1 and 2, there were no significant differences in patient satisfaction at 6 weeks or 3 months. In addition, the wound closure methods did not produce differing cosmetic outcomes. CONCLUSIONS: Although significant, the closing time for each method did not differ by a clinically relevant amount. Staples were the most cost-effective closing method, followed by Dermabond PRINEO. As neither method was superior over the other in terms of patient satisfaction, adverse events, and cosmetic outcomes, cost-effectiveness may be the greatest differentiator between the 3 methods.

High-Pressure Injection Injuries of the Hand: A 10-Year Retrospective Analysis at a Single Academic Center.

INTRODUCTION: The incidence of high-pressure injection injuries of the hand is low. Although the occurrence is rare, the precarious progression of the injury exacts prompt surgical evaluation in order to avoid complications and amputation. The current study was devised in order to make comparisons to the current data, in addition to supplementing the literature with observations regarding clinical course and management. METHODS: A multisurgeon, retrospective chart review from a single institution was performed. Inclusion criteria included cases involving a high-pressure injection injury to the hand that underwent surgical management. Patient demographics, injury details, and hospital course were all reviewed and recorded. RESULTS: This retrospective review identified 20 cases meeting criteria, all of which involved males. The average age at time of injury was 39.7 years (range, 21-71 years). The incidence of injection injuries over a 10-year time period was 2.1 cases per year. The nondominant hand was injured in 11 cases (63%). The most common site of injury was the index finger with 11 recorded incidents (55%). Other reported locations included the metacarpal (40%) and small finger (5%). Occupational data included 10 construction workers, 5 painters, and 2 cleaning crew members, and 3 had nonmanual occupations. Paint was the most commonly injected substance with 17 reported cases (85%). On average, the delay until surgery was observed to be 21.9 hours (n = 16). Only 1 patient underwent surgery at 6 hours after surgery. The average number of procedures performed was 1.8 (range, 1-4). Hospitalization duration was on average 3.9 days (range, 1-9 days), and the average follow-up length was 69 days (range, 7-112 days). There were no identified cases that necessitated amputation. CONCLUSIONS: This form of injury most commonly affects male, middle-aged laborers. Our study found very low amputation rates when compared with the current literature, despite observing longer delays to surgery according to current recommendations. Limited comparisons can be made from data regarding clinical course and management because of the small sample size of the current study and the limited published data. This indicates a need for further exploration and collection of data involving parameters such as clinical course and management.

Impact of COVID-19 on Away Rotations in Surgical Fields.

The COVID-19 pandemic has presented a variety of challenges in the medical education curriculum, one of which is the possible loss of summer and fall away rotations for fourth year students applying into surgical subspecialties. Subsequently, a lack of in-person evaluations may have a major impact on an applicant's perception of the residency and the program's ability to assess the individual applicant. This is especially crucial for applicants without a home program in their specialty of interest, as away rotations are an important opportunity to confirm interest in pursuit of a subspecialty, obtain letters of recommendation, and make positive impressions at programs of interest. The objective of this article is to assess the current COVID-19 pandemic situation in light of away rotations and to provide recommendations for surgical subspecialty programs and applicants to have the best outcome during this upcoming application cycle. In particular, we emphasize the importance of implementing universal processes within each individual subspecialty. This will provide equitable opportunities for all applicants, minimizing potential biases or disadvantages based on geographic location or availability of a program at an applicant's home institution.

The Bikini Inset: a reliable method for postradiation breast reconstruction with transverse rectus abdominis myocutaneous and free abdominal tissue transfer.

The combination of radiation and mastectomy reduces the 3-dimensional topography of the breast into a relatively inelastic, 2-dimensional plane. This environment presents specific challenges to aesthetic breast reconstruction with autologous tissue transfer, and a relative sparsity of information exists in the surgical literature on how to address these challenges. Accordingly, this article details a formalized and reproducible approach for flap inset in postradiation breast reconstruction. We outline a novel technique for optimizing the recipient bed and present a sequential flow for contouring the autologous abdominal flap, so that it recreates the individual subunits of an aesthetic breast.

A Comparison of Barbed Suture Versus Traditional Techniques for Muscle Belly Repair.

BACKGROUND: The use of barbed sutures in wound closure and tendon repair has been previously been studied with improved results over traditional suture material. We examine the use of barbed suture in muscle belly repair in a custom configuration, comparing it with traditional configurations and a control. METHODS: Twenty-five matched porcine psoas muscles were assigned to 5 different test groups: Mason-Allen with #1 Ethibond, Figure of Eight Allen with #1 Ethibond, Modified Kessler with #1 Ethibond, Custom Configuration with #2 Barbed PDS, Custom Configuration with #1 Ethibond. Repair was performed on the cut edge of muscle, with the free end of the suture anchored to a fixed base, forming a single-sided repair. An Instron 8874 tensiometer was used to linearly distract the repair to failure at 1 mm/s after 1 N preload. Five samples of each group were run, comparing load to failure and distraction at 10 N. RESULTS: Repair with barbed suture in custom configuration had statistically significantly greater load to failure than all other methods. It also showed statistically significant less displacement at 10 N of force than all other methods of repair except the Mason-Allen repair with #1 Ethibond. Mode of failure for traditional techniques was suture pull-through with tissue loss. Failure with barbed suture was through suture pullout without tissue loss. CONCLUSIONS: Custom configuration with a barbed suture increases the load to failure and decreases displacement of the repair site at 10 N of force. In addition, when the suture does pull out, it does so with minimal tissue loss.

Quantification of mechanical stabilization for the performance of off-pump coronary artery surgery.

INTRODUCTION: Our objective was to analyze the motion of a coronary artery in 3-dimensional (3-D) space and to quantify the stabilization afforded by a mechanical arm using 3-D digital sonomicrometry. METHODS: The left anterior descending coronary artery (LAD) was exposed in swine (n = 7) via sternotomy. A 2-mm sonomicrometry crystal was sutured to the LAD, and an acrylic (Plexiglas) ring with 3 2-mm crystals fixed in an equilateral triangle was placed in the oblique pericardial sinus. Sonomicrometry measurements were obtained before and 10 minutes after placement of a stabilizing arm. Traces were analyzed for motion and velocity on a beat-to-beat basis in the x, y, and z planes by means of triangulation theory. Excursion was defined as the average maximum observed distance between LAD Cartesian positions p(k) = [px(k),py(k),pz(k)] over a beat such that the Excursion = max(j,k in beat) sqrt ([px(j) - px(k)]2 + [py(j) - py(k)]2 + [pz(j) - pz(k)]2). The maximum and the average of the Cartesian velocity magnitude, v = sqrt[vx(2) + vy(2) + vz(2)], were also calculated. RESULTS: Analysis of the LAD motion in planar space demonstrated a biphasic pattern in all 3 planes that appeared to be stable through the duration of the data acquisition period. The stabilizer dampened the motion of the LAD to a monophasic pattern and reduced the total distance traveled by the LAD crystal in all 3 planes. Stabilization resulted in a significant reduction of excursion, the maximum Cartesian velocity, and the average Cartesian velocity of the LAD. CONCLUSIONS: This method allows the precise quantification of LAD artery motion in 3-D space before and after the application of a stabilizing arm. We have demonstrated a significant reduction in the complexity of motion, the degree of motion in planar space, and the velocity of the LAD after application of a stabilizer.

Necrotizing Soft Tissue Infection Occurring after Exposure to Mycobacterium marinum.

Cutaneous infections caused by Mycobacterium marinum have been attributed to aquarium or fish exposure after a break in the skin barrier. In most instances, the upper limbs and fingers account for a majority of the infection sites. While previous cases of necrotizing soft tissue infections related to M. marinum have been documented, the importance of our presenting case is to illustrate the aggressive nature of M. marinum resulting in a persistent necrotizing soft tissue infection of a finger that required multiple aggressive wound debridements, followed by an amputation of the affected extremity, in order to hasten recovery.

An algorithmic approach to breast reconstruction using latissimus dorsi myocutaneous flaps.

BACKGROUND: Innovative surgical techniques developed by surgical oncologists have changed the landscape of mastectomy defects. Latissimus dorsi myocutaneous flap-based breast reconstruction provides a reliable foundation for breast reconstruction. The purpose of this study was to evaluate differential skin island designs with latissimus dorsi myocutaneous flap breast reconstruction, and to develop an algorithmic approach to breast reconstruction that is applicable to a broad spectrum of mastectomy defects. METHODS: In this study, the authors retrospectively reviewed data of patients who underwent latissimus dorsi myocutaneous flap reconstruction following unilateral or bilateral mastectomies between February of 2001 and April of 2005. Patients were selected to undergo reconstruction under the following circumstances: (1) previously irradiated tissue, (2) body mass index greater than 30, (3) current tobacco use, (4) previous abdominopelvic surgery, and (5) patient preference. Patients were divided into three groups based on defect present: intact inframammary fold with skin deficit, intact inframammary fold without skin deficit, and absent inframammary fold with or without skin deficit. Differential skin island design was customized to the presenting mastectomy defect to optimize results and minimize donor-site scaring. RESULTS: Fifty-four patients underwent 64 latissimus dorsi myocutaneous flap reconstructions. Aesthetic outcomes and donor-site scar placement differed between groups. CONCLUSIONS: The authors have developed an algorithmic approach to latissimus dorsi myocutaneous flap breast reconstruction. Through critical evaluation of mastectomy defects, reconstructive breast surgeons can tailor skin island orientation, minimize donor-site scarring, enhance cosmetic outcomes, and provide a durable and natural aesthetic outcome in breast reconstruction with the latissimus dorsi myocutaneous flap.