Faculty Bibliography

BACKGROUND:The gracilis flap is a versatile muscle flap that can be utilized as a muscle only or myocutaneous flap for soft tissue coverage, as well as for reconstruction of facial animation or extremity function. Few studies have compared donor site complications of free and pedicled gracilis flaps, including the effect of skin paddle harvest on donor site morbidity. METHODS:We performed a retrospective review of patients who underwent a free or pedicled gracilis flap at our institution from 2013-2023. Gracilis flaps were categorized as: pedicled gracilis muscle flaps used for vaginectomy in gender reaffirming surgery, free gracilis muscle flaps, and free gracilis myocutaneous flaps. Outcome variables were duration of drain placement and complications including seroma, hematoma, infection, dehiscence, and persistent numbness. RESULTS:We identified 128 gracilis flaps including 19 free myocutaneous flaps, 35 free muscle flaps, and 74 pedicled muscle flaps. Free myocutaneous flaps required longer drain placement as compared to free muscle flaps or pedicled flaps (13.6 vs 8.4 vs 7.4 days, respectively, p=0.002). Free myocutaneous flaps displayed a higher complication rate (36.8%) as compared to pedicled muscle flaps (10.8%), or free muscle flaps (11.4%, p=0.020). After adjusting for age, BMI, and ASA status, free myocutaneous flaps demonstrated higher odds of major donor site complication as compared to pedicled muscle flaps (OR 1.23, p<0.001), while free muscle flaps were not associated with increased odds of major complication (OR 1.08, p=0.117). Of the documented complications, the most common were surgical site infection (36.8%), hematoma (21.1%) and seroma (21.1%). CONCLUSION/CONCLUSIONS:The inclusion of a skin paddle during gracilis flap harvest is associated with increased duration of drain placement and donor site complications including surgical site infection, hematoma, and seroma. These factors should be carefully considered in the context of patients' reconstructive needs and other risk factors.

BACKGROUND:The "July Effect" refers to the potential increase in adverse outcomes associated with the annual turnover of medical trainees, though its impact on surgical fields remains uncertain. Additionally, few studies have examined whether the operative day of the week and subsequent flap monitoring during the weekend affect time to reoperation or flap salvage. This study investigated whether academic quarter and operative day influence reoperation rates, flap salvage, or flap failure in microvascular free flap procedures. METHODS:A retrospective review was conducted on 769 free flaps performed between June 2011 and November 2023. Multivariate analyses adjusted for patient demographics, comorbidities, flap type, and recipient region. Flaps were categorized by academic quarter and operative day, excluding weekends due to limited sample size. Primary outcomes included reoperation rates for vascular compromise, time to reoperation, and flap salvage. RESULTS:No significant differences in reoperation rates for vascular compromise were observed across academic quarters. While procedure duration trended longer in the first three quarters compared to the fourth, these differences were not statistically significant. Additionally, operative day did not impact reoperation rates, flap salvage, or time to reoperation. Flaps were predominantly indicated for head and neck reconstruction (74.4%) and had an overall flap loss rate of 3.0%. CONCLUSION/CONCLUSIONS:We found no evidence of a "July Effect" in microvascular surgery or that operative day affects free flap outcomes. Institutional factors, such as structured flap monitoring, attending oversight, and advanced practice provider support, likely mitigate risks associated with trainee turnover and shift-based staffing fluctuations.

BACKGROUND: While prior studies have recommended immediate flap coverage within 72 hours of injury for soft tissue reconstruction for traumatic extremity injuries, recent evidence in the setting of advanced wound care techniques de-emphasizes the need for immediate coverage. Negative-pressure wound therapy (NPWT) has been an essential tool for extending the time to definitive soft tissue coverage. This study sought to elucidate the impact of preoperative NPWT use on the success of microsurgical reconstruction. METHODS: A literature search was conducted using the following databases from their inception up to February 2023: PubMed, OVID databases (Embase and Cochrane Library), Web of Science, and Scopus. Of 801 identified articles, 648 were assessed and 24 were included. Cases were divided based on whether NPWT was used preoperatively or not. Timing to definitive coverage, injury details, and basic demographics were recorded. Rates of flap failure, infection, bone nonunion, reoperation, and complications were compared between groups. RESULTS: A total of 1,027 patients and 1,047 flaps were included, of which 894 (85.39%) received preflap NPWT. The average time to definitive coverage for the NPWT and non-NPWT groups was 16 and 18 days, respectively. The NPWT group experienced lower postoperative complication rates than the non-NPWT group in all reported complications except for deep infections. Compared with the non-NPWT group, the NPWT group experienced lower rates of any flap failure (3.69 vs. 9.80%) and partial flap failure (2.24 vs. 6.54%). CONCLUSION/CONCLUSIONS: Preoperative NPWT was associated with reduced postoperative complications, most importantly flap failure rates. This merits further investigation into the decision-making process for traumatic extremity reconstruction. Future prospective studies adopting standardized protocols with longer follow-up are required to better understand the potentially beneficial role of preoperative NPWT use in soft tissue reconstruction.

BACKGROUND:Zygomatic arch (ZA) fractures are a common facial fracture, and reduction is typically performed blind via a Gillies or Keen approach. Postoperative confirmation of reduction thus requires advanced imaging, which may not be readily available in all settings. Thus, there exists a need for an effective, low-cost imaging paradigm to employ in these clinical scenarios. Herein, we introduce the ultrasonic arch reduction (USA Reduction) for ZA fractures. METHODS:All consecutive patients with ZA fractures undergoing a USA Reduction at a single public hospital were reviewed. Patients were operated on by two plastic surgeons. A standard Gillies approach was used in all cases in conjunction with real-time intraoperative ultrasound. All relevant patient data were collected and analyzed. RESULTS:Two patients were included in our study. Patient 1 was a 43-year-old man who was assaulted and sustained a right comminuted zygomatic arch fracture without concomitant trauma. Patient 2 was a 35-year-old man who was hit by a train and sustained a left comminuted ZA fracture in addition to traumatic subarachnoid hemorrhage. Both fractures were successfully reduced under ultrasound guidance in under 1 hour of operating room (OR) time without necessitating the use of postoperative CT. To date, both patients endorse positive postoperative satisfaction with their results. CONCLUSIONS:Intraoperative ultrasound is a safe and effective tool for confirming reduction of ZA fractures in a resource-limited practice while obviating the need for additional radiation. Further investigations to standardize the technique and approach will be useful to optimize this intraoperative adjunct.

BACKGROUND/UNASSIGNED:. In this video article, we present the exploration of a complex BPI in which the creation of a gracilis free flap is executed for elbow flexion reconstruction. We provide a comprehensive guide from markings, flap elevation, microsurgical technique, and inset, with educational operative pearls at every step. DESCRIPTION/UNASSIGNED:The procedure involves harvesting the gracilis muscle as a free functioning muscle transfer. The gracilis, which will become a type-II muscle flap, is carefully dissected with its pedicle and nerve preserved. The muscle is then transferred to the upper extremity, where its proximal origin is anchored to the clavicle and its distal tendon is inserted into the biceps tendon with use of a Pulvertaft weave. Vascular anastomoses are performed utilizing branches of the thoracoacromial trunk and venous couplers under a microscope. The muscle is innervated with the spinal accessory nerve and tensioned to ensure optimal elbow flexion. ALTERNATIVES/UNASSIGNED:Surgical alternatives include nerve transfers (e.g., Oberlin transfer), tendon transfers, or other free muscle transfers (e.g., latissimus dorsi transfer). Nonsurgical alternatives include orthotic devices to compensate for elbow flexion loss, and physical therapy to maximize existing function. RATIONALE/UNASSIGNED:. Unlike orthotic devices, this technique provides active elbow flexion, critical for functional independence. The long tendon and reliable vascular pedicle make the gracilis ideal for this purpose. EXPECTED OUTCOMES/UNASSIGNED:. These findings suggest that free gracilis muscle transfer provides reliable functional improvements, enabling meaningful elbow flexion restoration and enhancing quality of life. IMPORTANT TIPS/UNASSIGNED:Utilize Doppler ultrasound to confirm the location of a skin perforator over the gracilis to aid in postoperative monitoring.Preoperative markings are key. Mark the orientation of the gracilis muscle belly and pedicle preoperatively for efficient harvesting.The gracilis inserts distal to the knee, so extending the knee can help distinguish it from the adductor longus.Preserve all fascia over the gracilis muscle to optimize muscle gliding.Ensure proper resting tension during gracilis insertion to prevent over- or under-tightening, optimize function, and avoid complications like hyperextension or limited flexion.Position the elbow at 90° of flexion and the forearm in supination when tensioning.Make accommodation for any vessel size mismatch between the gracilis pedicle and recipient vessels to minimize complications.Confirm intraoperative vessel patency with use of Doppler flow checks after completing the anastomoses.Confirm nerve viability intraoperatively with use of nerve stimulation, ensuring a strong muscle contraction response.Secure the nerve repair without tension and with the appropriate coaptation in order to maximize reinnervation success.Utilize drains to avoid fluid collections that can create pressure on the pedicle.Place the gracilis tendon insertion precisely with use of the Pulvertaft weave technique, ensuring secure fixation and proper alignment with the biceps tendon. ACRONYMS AND ABBREVIATIONS/UNASSIGNED:BPI = brachial plexus injuryDASH = Disabilities of the Arm, Shoulder and HandDVT = deep vein thrombosisEMG = electromyographyFFMT = free functioning muscle transferFGMT = free gracilis muscle transferICN = intercostal nerve transferM3/M4 = muscle strength grade 3 or 4MCA = medial circumflex arteryMCN = musculocutaneous nerveNCS = nerve conduction studyPPX = prophylaxisSAN = spinal accessory nerveSF-36 = Short Form-36.

BACKGROUND/UNASSIGNED:Our objective is to evaluate the utilization fraction (UF) of surgical instruments during a commonly performed ambulatory hand surgery case as an avenue for cost reduction, increased operating room efficiency, and systems quality improvement. METHODS/UNASSIGNED:The total number of instruments opened at the start of the case was recorded followed by instruments being divided into those used and not used during the procedure. Total sterile processing costs were estimated at $1.56 per instrument according to data from our institution's central sterilization processing (CSP) department. RESULTS/UNASSIGNED:Nineteen hand procedures performed by 2 surgeons were included in this study. An average of 120.1 ± 10.9 instruments were opened at the start of each case, while an average of 12.6 ± 5.4 instruments were used per case (Figure 1). This yielded an UF of 10.7% ± 4.8%. Using our internal CSP estimate, we calculated an annual cost of $16 863 to reprocess the current hand tray (Figure 2). Using literature data, this cost ranged from $5 513 to $34 484 annually. The same cost calculations were performed for the theoretical optimized tray (incorporating instruments used at least 20% of the time when opened) containing 23.2 instruments. The annual reprocessing cost of this new tray according to CSP data was $3 260, demonstrating a cost-reduction of $13 603 or 80.7% (Figure 2). CONCLUSIONS/UNASSIGNED:Evaluation of pre- and peri-operative processes is a valuable technique to mitigate increasing healthcare costs and reduce unnecessary healthcare spending, with broad applicability to multiple surgical subspecialties and procedures.

This case series describes the successful use of indocyanine green dye and near infrared fluorescence imaging in primary peripheral nerve repair.

PURPOSE/OBJECTIVE:Offering the benefits of rigid fixation while minimizing soft tissue dissection, intramedullary implants have become a popular choice among hand surgeons. Their placement often requires traversing or passing in proximity to joint surfaces. This study aimed to assess the damage to the articular cartilage of the base of the proximal phalanx resulting from antegrade placement of threaded headless intramedullary nails. METHODS:A cadaveric study comparing two techniques for antegrade placement of threaded headless intramedullary nails was conducted in 56 digits. The first entailed a single 2.1 mm intramedullary nail placed via the dorsal base of the proximal phalanx, whereas the second used two 1.8 mm intramedullary nails inserted via the collateral recesses of the phalangeal base. All specimens were analyzed for articular surface damage with the cartilage defect measured as a percentage of total joint surface area. Damage to the extensor tendons was also assessed in a subset of specimens. RESULTS:No significant difference in the percentage of articular surface damage was observed, with an average 3.21% ± 2.34% defect in the single 2.1 mm nail group and a 2.71% ± 3.42% mean defect in the two 1.8 mm nails group. There was no articular surface injury in 18% of digits in each group. Damage to extensor tendons was seen in three (9.4%) specimens and in all cases involved either the extensor indicis proprius or extensor digiti minimi. CONCLUSIONS:Hardware insertion using either the dorsal base of the proximal phalanx or the collateral recesses of the phalangeal base both demonstrated minimal articular cartilage damage and infrequent injury to the extensor tendons. CLINICAL RELEVANCE/CONCLUSIONS:With proper technique for antegrade insertion into the proximal phalanx, the cartilage defect observed often encompasses only a small percentage of the overall joint surface area.

PURPOSE/OBJECTIVE:The study investigates whether the intraoral approach to mandibular open reduction and internal fixation, through exposure to the oral cavity's microbiome, results in higher infection rates compared to the extraoral approach, thus addressing a critical public health concern, health-care costs, and aiming to guide effective clinical practice. METHODS:statistics). RESULTS: = 84% for intraoral and 56% for extraoral). CONCLUSION/CONCLUSIONS:Our meta-analysis found no significant difference in infection rates between the two approaches. There is opportunity to expand on reporting complication rates comparing the various approaches to mandibular fixation. Until these data are presented, surgeon preference may dictate the operative approach to expose the mandible for reduction and fixation.

BACKGROUND:An update on the epidemiology of distal radius fractures in the United States is necessary, particularly as the elderly population grows. Additionally, age and frailty have been associated with complications following surgical fixation of DRFs. Herein, we utilize the National Trauma Data Bank, a robust nationwide resource, to investigate the relationship between demographics, comorbidities, injury and fracture characteristics, and admission details. METHODS:Patients with isolated distal radius fractures were identified from the National Trauma Data Bank (2016-2019) according to ICD-10 codes. Univariate and multivariate regressions were conducted to determine independent risk factors for bilateral fractures, displaced fractures, open fractures, as well as length of hospital stay and adverse discharge disposition for patients undergoing inpatient surgical fixation. RESULTS:The incidence of DRFs was 3.6/1,000 trauma-related emergency department visits and 10.8/1,000 upper extremity traumas. Trauma mechanism was significantly associated with displaced and open fractures. Age (OR 1.01, 95% CI 1.01-1.01), BMI (OR 1.02, 95% CI 1.01-1.02), smoking (OR 1.34, 95% CI 1.15-1.57), and alcohol level (trace: OR 2.18, 95% CI 1.41-3.29; intoxicated: OR 2.20, 95% CI 1.63-2.95) were significantly associated with open fractures. Machinery (β=2.04, 95% CI 1.00-3.08) and MVT (β=0.39, 95% CI 0.08-0.69) mechanisms were independent risk factors for longer length of stay. mFI-5 was an independent risk factor, in a stepwise fashion, for both length of stay and adverse discharge disposition. CONCLUSIONS:High-energy mechanisms and risk factors for poor skin quality were significantly associated with open fractures. mFI-5 was an independent risk factor for longer length of stay and non-routine discharges in patients of all ages, despite controlling for other comorbidities, unrelated complications, and mechanism of injury. Trauma mechanism was an independent risk factor for prolonged length of stay only, particularly in patients younger than 65 years of age.