Background
The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes ...following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow.
Methods
This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes.
Results
Twenty‐one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, 57%). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, 5%); partial dehiscence (n = 5, 24%); seroma (n = 2, 10%); donor‐site hematoma (n = 1, 5%); and delayed wound healing (n = 5, 24%). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow‐up.
Conclusion
Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.
A disparity exists in patients receiving panniculectomies. We evaluated this disparity and assessed if it persists once patients are integrated into the healthcare system through bariatric surgery.
...All patients who received bariatric surgery (n = 2528), panniculectomies (n = 1333) and panniculectomies after bariatric surgery (n = 48) at the University of Pennsylvania between January 1, 2012 and March 1, 2017 were retrospectively identified. Demographic information and post-operative details were collected. Univariate and multivariate analyses were performed.
43% (n = 1087) of bariatric surgery patients were African-American compared to 25% (n = 339) of all panniculectomy patients and 52% (n = 25) of panniculectomy after bariatric surgery patients. The racial disparity among all patients receiving a panniculectomy was not present in patients receiving bariatric surgery beforehand (p < 0.001). The average income of patients receiving a panniculectomy for any etiology ($89,000) was significantly higher (p < 0.001) than patients receiving a panniculectomy after bariatric surgery ($71,000). After multivariate analysis, race remained associated with the disparity (p = 0.046).
The disparity seen in patients receiving panniculectomies is not present when patients are integrated into the healthcare system through bariatric surgery.
•A racial disparity exists among patients that receive panniculectomies.•This disparity does not exist in patients receiving bariatric surgery beforehand.•Further studies are needed to determine at what level the disparity lies.
A racial disparity exists among all patients receiving panniculectomies, but this disparity is not observed in patients that receive bariatric surgery prior to receiving a panniculectomy. Exploring this sub-population of patients receiving panniculectomies may be the key to improving the overall disparity.
Incisional hernias (IH) following abdominal surgery are frequent and morbid. Prophylactic mesh augmentation (PMA) has emerged as a technique to reduce IH formation. We aim to report patient ...selection, techniques and early outcomes after PMA.
Retrospective chart review identified descriptive characteristics, risk factors, operative technique, and early post-operative outcomes for PMA patients and matched non-PMA patients between January 1, 2016 and October 31, 2017.
18 consecutive PMA cases were performed (55.6% female, mean age 54.3 years and mean BMI = 29.5 kg/m2). 88.9% of patients had at least two high-risk features for IH. Zero PMA patients developed IH compared to 5.3% non-PMA patients (p = 0.314) (6-months mean follow-up). No difference in surgical site occurrences (SSO) were identified between the two groups.
Early results are encouraging, demonstrating PMA is safe with equivocal SSO. Further studies are needed to assess if the reduction in IH formation is statistically significant with longer follow-up.
•88.9% of patients receiving PMA had at least 2 risk factors for IH.•Average case length was 305 min and average time of mesh inset was 28 min.•No difference in surgical site outcomes between PMA and non-PMA patients.•Zero IH at 6 months with PMA compared to 5.3% in non-PMA patients (p = 0.314).
Observations of the long-lived emission-or 'afterglow'-of long-duration γ-ray bursts place them at cosmological distances, but the origin of these energetic explosions remains a mystery. Observations ...of optical emission contemporaneous with the burst of γ-rays should provide insight into the details of the explosion, as well as into the structure of the surrounding environment. One bright optical flash was detected during a burst, but other efforts have produced negative results. Here we report the discovery of the optical counterpart of GRB021004 only 193 seconds after the event. The initial decline is unexpectedly slow and requires varying energy content in the γ-ray burst blastwave over the course of the first hour. Further analysis of the X-ray and optical afterglow suggests additional energy variations over the first few days.
Soft-tissue reconstruction of the scalp has traditionally been challenging in oncologic patients. Invasive tumors can compromise the calvarium, necessitating alloplastic cranioplasty. Titanium mesh ...is the most common alloplastic material, but concerns of compromise of soft-tissue coverage have introduced hesitancy in utilization. The authors aim to identify prognostic factors associated with free-flap failure in the context of underlying titanium mesh in scalp oncology patients.
A retrospective review (2010-2018) was conducted at a single center examining all patients following oncologic scalp resection who underwent titanium mesh cranioplasty with free-flap reconstruction following surgical excision. Patient demographics, comorbidities, ancillary oncological treatment information were collected. Operative data including flap type, post-operative complications including partial and complete flap failure were collected.
A total of 16 patients with 18 concomitant mesh cranioplasty and free-flap reconstructions were identified. The majority of patients were male (68.8%), with an average age of 70.5 years. Free-flap reconstruction included 15 ALT flaps (83.3%), 2 latissimus flaps (11.1%), and one radial forearm flap (5.5%). There were three total flap losses in two patients. Patient demographics and comorbidities were not significant prognostic factors. Additionally, post-operative radiation therapy, ancillary chemotherapy, oncological histology, tumor recurrence, and flap type were not found to be significant. Pre-operative radiotherapy was significantly associated with flap failure (P < 0.05).
Pre-operative radiotherapy may pose a significant risk for free-flap failure in oncologic patients undergoing scalp reconstruction following mesh cranioplasty. Awareness of associated risk factors ensures better pre-operative counseling and success of these reconstructive modalities and timing of pre-adjuvant treatment.
We measure the angular correlation function of radio galaxies selected by the 843-MHz Sydney University Molonglo Sky Survey (SUMSS). We find that the characteristic imprint of large-scale structure ...is clearly detectable and that the survey is very uniform. Through comparison with similar analyses for other wide-area radio surveys – the 1400-MHz National Radio Astronomy Observatories Very Large Array Sky Survey (NVSS) and the 325-MHz Westerbork Northern Sky Survey – we are able to derive consistent angular clustering parameters, including a steep slope for the clustering function, w(θ) ∝θ−1.1. We revise upwards previous estimates of the NVSS clustering amplitude, and find no evidence for dependence of clustering properties on radio frequency. It is important to incorporate the full covariance matrix when fitting parameters to the measured correlation function. Once the redshift distribution for mJy radio galaxies has been determined, these projected clustering measurements will permit a robust description of large-scale structure at z∼ 0.8, the median redshift of the sources.
An increasing number of plastic and reconstructive surgery (PRS) units have transitioned from divisions to departments in recent years. This study aimed to identify quantifiable differences that may ...reflect challenges and benefits associated with each type of unit. We conducted a cross-sectional analysis of publicly-available data on characteristics of academic medical institutions housing PRS units, faculty size of surgical units within these institutions, and academic environments of PRS units themselves. Univariate analysis compared PRS divisions versus departments. Matched-paired testing compared PRS units versus other intra-institutional surgical departments. Compared to PRS divisions (n = 64), departments (n = 22) are at institutions with more surgical departments overall (P = 0.0071), particularly departments that are traditionally divisions within the department of surgery (ie urology). Compared to PRS divisions, PRS departments have faculty size that more closely resembles other intra-institutional surgical departments, especially for full-time surgical faculty and faculty in areas of clinical overlap with other departments like hand surgery. Plastic and reconstructive surgery departments differ from PRS divisions by certain academic measures, including offering more clinical fellowships (P = 0.005), running more basic science laboratories (P = 0.033), supporting more nonclinical research faculty (P = 0.0417), and training residents who produce more publications during residency (P = 0.002). Institutions with PRS divisions may be less favorable environments for surgical divisions to become departments, but other recently-transitioned divisions could provide blueprints for PRS to follow suit. Bolstering full-time surgical faculty numbers and faculty in areas of clinical overlap could be useful for PRS divisions seeking departmental status. Transitioning to department may yield objective academic benefits for PRS units.
Purpose. Powered by big data, predictive models provide individualized risk stratification to inform clinical decision-making and mitigate long-term morbidity. We describe how to transform a large ...institutional dataset into a real-time, interactive clinical decision support mobile user interface for risk prediction. Methods. A clinical decision point ideal for risk stratification and modification was identified. Demographics, medical comorbidities, and operative characteristics were abstracted from the electronic medical record (EMR) using ICD-9 codes. Surgery-specific predictive models were generated using regression modeling and corroborated with internal validation. A clinical support interface was designed in partnership with an app developer, followed by subsequent beta testing and clinical implementation of the final tool. Results. Individual, specialty-specific, and preoperatively actionable models incorporating clustered procedural codes were created. Using longitudinal inpatient, outpatient, and office-based data from a large multicenter health system, all patient and operative variables were weighted according to ß-coefficients. The individual risk model parameters were incorporated into specialty-specific modules and implemented into an accessible iOS/Android compatible mobile application. Conclusions. As proof of concept, we provide a framework for developing a clinical decision support mobile user interface, through the use of clinical and administrative longitudinal data. Point-of-care applications, particularly ones designed with implementation and actionability in mind, have the potential to aid clinicians in identifying and optimizing risk factors that impact the outcome of interest’s occurrence, thereby enabling clinicians to take targeted risk-reduction actions. In addition, such applications may help facilitate counseling, informed consent, and shared decision-making, leading to improved patient-centered care.
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