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Proper injection of the posterior interosseous nerve (PIN) is important for both the therapeutic and diagnostic management of wrist pain. However, no anatomical study exists describing the site of injection based on individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN. Fresh frozen cadaver forearms were dissected at the University of Louisville tissue lab. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. A total of 16 cadaver forearms of equal male to female ratio were obtained. On average, the male forearm had a greater mean wrist circumference obtained at the level of Lister's tubercle compared to female forearms, 17.1 cm vs. 13.5 cm. An injection given ulnar to proximal edge of Lister's tubercle at a length of one-fourth the distance between Lister's tubercle and radial aspect of ulnar styloid resulted in 100% accurate perineural injection without intraneural injection. An anthropometric ratio of one-fourth the distance from Lister's tubercle to the ulnar styloid was able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions. [ABSTRACT FROM AUTHOR]

Objective: Lateral breast defects of various causes can be reconstructed with random patterned local flaps utilizing oncoplastic techniques. These local flaps are used frequently in other areas but are infrequent in breast reconstruction despite affording excellent utility in small lateral defects.We sought to demonstrate this with a case series involving 5 patients who underwent oncoplastic breast surgery with random patterned flap reconstruction. Methods: From 2016 to 2017, 3 different varieties of random flaps were used in 5 women requiring lateral breast defect reconstruction secondary to resection of localized cancer or cutaneous lesion. The local flaps included a rhomboid flap, the bilobed flap, and a rotational flap. Patients were then evaluated in the clinic 10 to 12 months postoperatively for complications, symmetry, and satisfaction of reconstruction. Results: In 4 of 5 patients, the local flap remained fully viable and therewas no incidence of seroma, infection, or further complications. One patient developed a post-operative hematoma requiring evacuation and a second patient experienced distal flap necrosis and delayed wound healing. Patients reported satisfaction with the reconstruction. Conclusions: Several random patterned local flaps exist for a variety of breast defects. They can yield excellent cosmetic results, high patient satisfaction, and bolster a low rate of complications. Our case series emphasizes the utility of random patterned flaps for lateral breast oncoplastic reconstruction. [ABSTRACT FROM AUTHOR]

Objective: Management of calcaneal wounds is challenging due to a paucity of tissue, complex local anatomy, and limited vascularity. These wounds are commonly associated with lower extremity fractures, which are often treated with external fixation. Free tissue transfers are frequently employed as a means for closure of plantar heel wounds; however, postoperative management can be challenging due to their dependent location. We sought to describe how simple modification of the external fixator can help relieve direct pressure, provide joint immobilization, and optimize accessibility necessary for flap survival. Methods: Three patients requiring autologous free tissue reconstruction of hindfoot defects were immobilized using an external fixator with a “kickstand” modification. Viability of the transferred tissue and the postoperative outcomes were assessed. Results: All free flaps survived with no associated complications. The “kickstand” modification was well tolerated with minimal discomfort. All 3 patients expressed satisfaction with early return to ambulation. Conclusion: An external fixator with a “kickstand” modification provides an essential function in maintaining the viability of the transferred tissue to plantar calcaneal wounds. [ABSTRACT FROM AUTHOR]

Background. In 2020, reduction mammoplasties and mastopexies comprised 34.2% of all breast surgeries performed by plastic surgeons. Various approaches for the skin incision of these procedures have been described. The vertical pattern has become an increasingly popular option due to its lower scar burden. However, it is prone to dog-ear formation along the caudal aspect of the incision. Herein, we describe 5 technical steps to eliminate the dog-ear in patients undergoing vertical mammoplasties. Methods. A retrospective chart review was performed on all patients who underwent vertical breast reduction and mastopexy between the years 2008 and 2020 performed by the senior author. The 5 steps employed in eliminating the dog-ear are delineated and depicted pictorially. Results. A total of 58 patients and 89 breasts were operated upon. A majority of 66.6% were Caucasian, 33.3% were African American, and 1 patient was of Hispanic descent. The mean age was 53.2 years (19-73 years), and average BMI was 31.5 kg/m² (21.3-42.7 kg/m²). The average resection weights for reduction and mastopexy patients were 479 grams (100-1500 grams) and 58.1 grams (18-100 grams), respectively. Mean follow-up was 10.5 months (1-35 months). Only one patient developed a dog-ear (1.7%) in bilateral breasts (2.2%); however, the patient did not request a revision. Our revision rate over 13 years remained at 0%. Conclusions. Utilizing these 5 technical steps reduces the risk of dog-ear deformity and thereby diminishes the overall need for revisional surgery in patients undergoing short scar vertical mammoplasties. [ABSTRACT FROM AUTHOR]

Background Pancreatic surgery is complex with the potential for costly hospitalization. Methods A retrospective review of patients undergoing a pancreatic resection was performed. Results The median age of the study population was 64 years. Half of the cohort was female (51%), and the majority were white (62%). Most patients underwent a pancreaticoduodenectomy ( PD) (69%). The pre-operative age-adjusted Charlson comorbidity index was zero for 36% ( n = 50), 1 for 31% ( n = 43) and ≥2 for 33% ( n = 45). The Clavien- Dindo grading system for post-operative complication was grade I in 17% ( n = 24), whereas 45% ( n = 62) were higher grades. The medians direct fixed, direct variable, fixed indirect and total costs were $2476, $15 397, $13 207 and $31 631, respectively. There was a positive contribution margin of $7108, whereas the net margin was a loss of $6790. On univariate analyses, age, type of operation and complication grade were associated with total cost ( P ≤ 0.05), whereas operation type and complication grade were associated with a net margin ( P = 0.01). These findings remained significant on multivariate analysis ( P < 0.05). Conclusions Increased cost, reimbursement and revenue were associated with type of operation and post-operative complications. [ABSTRACT FROM AUTHOR]

BACKGROUND: Eliminating catheter-associated urinary tract infections (CAUTI) is at the forefront of quality improvement and cost reduction for payers and hospitals alike. Herein we describe a double-focused strategy to eliminate CAUTI's on a surgical oncology unit over the course of 24 mo. METHODS: CAUTI's were tracked on a 30-bed surgical oncology unit 12 mo before and 12 mo after implementation of specific measures aimed at (1) decreasing utilization and (2) increasing catheter bundle and hand hygiene compliance. A policy of early Foley catheter removal was implemented. Univariate analyses were performed comparing nominal and numerical variables between the pre- and post-intervention groups. RESULTS: The pre- and post-intervention groups comprised of 1376 and 1467 patients, respectively. Postintervention, there was a significant decrease in both total Foley (P = 0.02) and patient (P = 0.03) days. This resulted in a significant reduction in utilization rate from 0.28 to 0.24, (P < 0.0001) and median CAUTI rate from 4.6 to 0.0 (P = 0.03). Reduced CAUTIs were associated with significant improvements in monthly bundle compliance at ⩾95% (75% versus 17%, P = 0.003) and hand hygiene compliance at ⩾95% (92% versus 58%, P = 0.05). Among our thoracic epidural cohort (n = 11), three patients (27%) required reinsertion for urinary retention. None of these epidural patients were diagnosed with a CAUTI. CONCLUSIONS: Although not eliminated entirely, CAUTIs on our unit were significantly reduced through decreased utilization and improved compliance to institutional patient safety measures. Adoption of these strategies to other inpatient units would not only improve patient safety but also result in significant cost savings. [ABSTRACT FROM AUTHOR]

Duodenal neuroendocrine tumors are rare but increasing in incidence and optimal management is hindered by lack of duodenum-specific staging. Duodenal carcinoids were identified in the Surveillance, Epidemiology and End Results tumor registry. Depth of invasion was defined as limited to lamina propria (LP), invading muscularis propria (MP), through muscularis propria (TMP), and through serosa (S). Nine hundred forty-nine patients were identified with majorities being male (57%), white (70%), and node-negative (87%). Tumor size (cm) was less than 1, 47 per cent; 1 to 2, 35 per cent; and greater than 2, 8 per cent with 76 per cent LP. Lymph node (LN) involvement was associated with age, depth of invasion (LP 4%, MP 28%, TMP 54%, and S 57%) and size (less than 1 cm, 3%; 1 to 2 cm, 13%; and greater than 2 cm, 40%). Using the current T staging, LN involvement was: T1 (LP) 2 per cent, T2 (MP or greater than 1 cm) 13 per cent, T3 (TMP) 54 per cent, and T4 (S) 57 per cent. We reclassified current T1 to Tla and current T2 stage to Tib (1 to 2 cm and LP) and T2 (MP or greater than 2 cm). LN metastasis for Tib tumors was 4.7 per cent compared with 20.8 per cent for T2. The resulting TNM classification better defines 5-year disease-specific survival. Our modified staging schema identifies a low-risk group (Tla and Tib) that may be considered for local therapy. [ABSTRACT FROM AUTHOR]

Patients undergoing pancreatic resection are at risk for developing postoperative exocrine dysfunction. We sought to determine the incidence of and clinical factors associated with exocrine dysfunction after pancreatectomy. A retrospective review of a prospective database composed of patients undergoing pancreatic resection between 2004 and 2013 was performed. Logistic regression was used to identify preoperative factors that influenced postoperative exocrine insufficiency. One hundred sixty-one patients with complete follow-up were identified. The mean age was 64.1 ± 12.65 years. The majority were: female (51%), white (66%), tobacco users (61%), nondrinkers (68%), nondiabetic (71%), and without preoperative exocrine dysfunction (96%). Average body mass index was 27.8 ± 6.32 kg/m². Most underwent a pancreaticoduodenectomy (67.3%) for pancreatic cancer (59.6%). Pancreatic fistula occurred in 6.8 per cent. Seven patients were on enzyme replacement therapy preoperatively. Forty-four patients (27%) had postoperative exocrine dysfunction (five of whom were on enzyme replacement therapy preoperatively). Two of seven (29%) of patients with preoperative exocrine dysfunction had complete resolution of their exocrine dysfunction. On univariate analysis, only the type of operation (Whipple) was significantly associated with exocrine dysfunction (P = 0.04). On multivariate analysis, both female gender and type of operation were independently associated with postoperative exocrine dysfunction (P = 0.05). Pancreatic exocrine dysfunction occurred less frequently in this population than what is commonly reported in the literature. Female patients undergoing resection of the pancreatic head have significantly increased risk of exocrine dysfunction. [ABSTRACT FROM AUTHOR]

Mortality from breast cancer in eastern North Carolina (ENC) surpasses the rest of North Carolina (RNC). We sought to identify modifiable factors associated with the increased mortality of women diagnosed with breast cancer in ENC. A retrospective cohort study of women diagnosed with breast cancer in North Carolina between January 1, 2004, and December 31, 2007 (n = 27,631) was studied. There was no difference in the pathologic T (P = 0.62), N (P = 0.26), or stage grouping (P = 0.25) at diagnosis. Women in ENC were less likely to be white (P < 0.001), estrogen receptor (ER)-positive (P < 0.001), progesterone receptor (PR)-positive (P < 0.001), or to receive adjuvant chemotherapy (P = 0.02). The median survival of ENC patients was worse than RNC patients (39 vs. 43 months, P = 0.003). Improved median survival was associated with ER status (P < 0.001), PR status (P < 0.001), race/ethnicity (P < 0.001), and delivery of timely chemotherapy (P < 0.0001). ER- negative status (P = 0.01), black race (P = 0.03), and adjuvant chemotherapy within 90 days of surgery (P < 0.001) remained significant predictors of survival. The poor outcomes observed in ENC can be attributed to recognized prognostic primary patient and tumor characteristics. However, a failure in process of care remains significantly associated with poorer outcomes. Improved timing of delivery of chemotherapy could affect breast cancer mortality. [ABSTRACT FROM AUTHOR]

Objective: Use of local anesthesia in awake patients undergoing hand surgery has become increasingly popular. A thorough understanding of local anatomy, such as the distal wrist for ulnar nerve block, is required to provide safe blockade. We sought to conduct an anatomic study of the distal wrist and review cadaveric studies describing various techniques for ulnar nerve block. Methods: Dissection of fresh-frozen cadaver forearms at the University of Louisville Robert Acland Fresh Tissue Lab assessing relationships between the flexor carpi ulnaris tendon and the ulnar nerve and the ulnar artery was performed. Three cadaveric studies on ulnar nerve blockade using the ulnar, volar, and/or transtendinous technique were identified and reviewed. Results: A total of 16 cadaver forearms of equal male to female ratio were obtained. The ulnar nerve was noted to be directly posterior to the flexor carpi ulnaris tendon in 15 (93.8%) forearms, with 1 (6.3%) specimen having the nerve extend along the ulnar border of the flexor carpi ulnaris. The ulnar artery was radial to the ulnar nerve 1 cm proximal to the pisiform in all specimens. In all 3 cadaveric studies, only the ulnar technique was associated with no ulnar artery and/or ulnar nerve injury. Conclusion: Knowledge of distal wrist anatomy can help minimize risk of iatrogenic injury during local blockade. On review, the ulnar approach provides the safest method for ulnar nerve block. [ABSTRACT FROM AUTHOR]

This article discusses a case of a 23-year-old man who presented with a firework-related injury to his face. The firework became lodged in his left jaw, and the bomb squad was called to safely remove the explosive. The patient underwent surgery to repair the facial fractures and restore function and aesthetics. The article also provides information on the epidemiology of firework-related injuries, the important considerations for managing facial injuries, and the potential causes of early and long-term morbidity following facial reconstruction. The case highlights the complex management required for facial injuries caused by fireworks and emphasizes the need for multidisciplinary care. [Extracted from the article]

Merkel cell carcinoma is a cutaneous neuroendocrine neoplasm that has been poorly studied in contemporary cohorts. Patients with Merkel cell carcinoma from 1986 to 2011 were identified in the Surveillance Epidemiology and End Results registry. A total of 5211 patients met the inclusion criteria. The mean age was 74.9 years; majority were male (61.4%) and white (94.9%). Patients were divided into two cohorts: Group 1 (1986 and 1999) and Group 2 (1999-2010). Group 2 was more likely to have Stage III disease (14.6 vs 23.3%, P < 0.001) and less likely to have Stage I/II disease (71.8 vs 65.1%, P < 0.0001). The increase in Stage III was likely secondary to increased use of sentinel lymph node biopsy. Disease-specific five-year survival for Stages I/II was 78.1 per cent and Stage III was 54 per cent. Disease-specific five-year survival was unchanged between Groups 1 and 2,69.9 versus 66.6 per cent, respectively (P = 0.44). Both incidence and mortality significantly increased over the study period with P value for both trends <0.0001. In 1986, incidence and mortality rates per 100,000 were 0.22 and 0.03, respectively, and increased to 0.79 and 0.43 in 2011, respectively. There has been a greater than 333 per cent increase in mortality from Merkel cell carcinoma. [ABSTRACT FROM AUTHOR]

Background The Hemodialysis Reliable Outflow (HeRO) vascular access device is a hybrid polytetrafluoroethylene graft-stent construct designed to address central venous occlusive disease. Although initial experience has demonstrated excellent mid-term patency rates, subsequent studies have led to external validity questions. The purpose of this study was to examine a single center experience with this vascular access device in challenging access cases with associated costs. Methods A retrospective study representing the authors' cumulative HeRO vascular access device experience was undertaken. The primary endpoint was graft failure or death, with secondary endpoints including secondary intervention rates and cost. Results Forty-one patients with 15,579 HeRO days and a mean of 12.7 ± 1.5 mo with the vascular access device were available for analysis. Secondary patency was 81.6% at 6 mo and 53.7% at 12 mo. The reintervention rate was 2.84 procedures per HeRO vascular access device year. Associated HeRO costs related to subsequent procedures were estimated at $34,713.63 per patient/y. Conclusions These data on the patency and primary outcome data diverge significantly from initial multicenter studies and represent a real-world application of this technology. It is costly to maintain patency. Use of HeRO vascular access devices should be judicious with outcome expectations reduced. [ABSTRACT FROM AUTHOR]

Puffy Hand Syndrome is a complication of intravenous (IV) drug abuse that causes swelling and edema in the hands. It was first described in prisoners in New York in 1965 and can affect up to 16% of IV drug users. The syndrome is characterized by non-pitting or minimally pitting edema, affecting the dorsal surface of the fingers and hands, and can progress to permanent swelling. The exact cause is not fully understood, but it is believed to be due to the sclerosing of the superficial venous system and lymphatics from IV injections of irritants commonly found in street drugs. There are currently no known medical or surgical treatments to reverse the swelling, and management focuses on symptomatic relief through elevation and compression. [Extracted from the article]

Outcomes are superior for pancreatic resection at high-volume centers. To assess the impact of focused high-volume multidisciplinary care, a quality index (QI) was used to review our experience. Data from 1996 to July 2012 were analyzed in three groups: 1) early (1996 to 2007); 2) transition (2008 to 2009); and 3) mature (2010 to July 2012). A total of 239 patients were included with a mean age of 63.4 years and the majority were white (65.7%). The number of patients with Charlson comorbidity index greater than 2 and age older than 80 years increased comparing Group I with latter groups. Volume increased over time: Group 1 (n = 93) 7.75/year, Group 2 (n = 51) 25.5/ year, and Group 3 (n = 95) 39/year. Overall mortality was 5.9 per cent: Group 1, 4.3 per cent; Group 2, 11.5 per cent; and Group 3, 3.9 per cent (P = 0.0454). The QI score incorporates documentation, chemotherapy, resection for Stage I/II, time to treatment, margins, lymph nodes, mortality, and surgical volume with a maximum possible score 10. The QI increased over time: 3 in Group 1; 4 in Group 2; and 6 in Group 3. An improvement was noted for the quality indicators: surgical resection (P = 0.0125) and use of palliative and adjuvant therapy (P = 0.0144 and < 0.0001). Implementation of a focused multidisciplinary pancreatic surgery program increases quality. [ABSTRACT FROM AUTHOR]

Purpose: Breast augmentation is the most commonly performed aesthetic operation in the Unites States annually. With the increasing popularity of gel implants, optimal incisional length for specific implant volumes becomes a factor to consider. Our study is the first, to date, to measure optimal incisional length for increasing Mentor smooth, round, moderate plus silicone implant volumes. Method: Three cadaver breasts were dissected in our anatomy laboratory. After dissection of a subpectoral pocket via an inframammary fold incision, time of implant insertion was measured for increasing volumes with the use of increasing incisional site lengths. Results: Values for increased incisions are as follows: 2.5-cm incision facilitated 100-cm3 implant (average time [AvgT] 76 seconds); 3-cm incision 100-cm3 implant (AvgT 32 seconds), 200 cm3 (AvgT 84.33 seconds); 3.5-cm incision 100-cm3 implant (AvgT 13.00 seconds), 200 cm3 (AvgT 22.00 seconds), 300 cm3 (AvgT 33.67 seconds); 4-cm incision 100-cm3 implant (AvgT 5.67 seconds), 200 cm3 (AvgT 11.33 seconds), 300 cm3 (AvgT 21.33 seconds), 400 cm3 (AvgT 26 seconds); 4.5-cm incision 100-cm3 implant (AvgT 5 seconds), 200 cm3 (AvgT 15.17 seconds), 300 cm3 (AvgT 19.67 seconds), 400 cm3 (AvgT 26 seconds), 500 cm3 (AvgT 39.67 seconds), 600 cm3 (AvgT 59.33 seconds), 700 cm3 (AvgT 78.67 seconds); 5-cm incision 100-cm3 implant (AvgT 1 second), 200 cm3 (AvgT 3.67 seconds), 300 cm3 (AvgT 8 seconds), 400 cm3 (AvgT 13 seconds), 500 cm3 (AvgT 19.33 seconds), 600 cm3 (AvgT 23.33 seconds), 700 cm3 (AvgT 28 seconds), 800 cm3 (AvgT 33 seconds). Conclusion: Based on our results, the optimal incision size for increasing Mentor smooth, round, moderate plus volumes is as follows: 2.5 cm for 100-cm3 implant, 3 cm for 200-cm3 implant, 3.5 cm for 300-cm3 implant, 4 cm for 400-cm3 implant, 4.5 cmfor 500- to 700-cm3 implant, and 5 cm for 800-cm3 implant. This guideline can be used to provide the most aesthetic results without tissue compromise. [ABSTRACT FROM AUTHOR]

Objective: The increase in demand for gluteal fat grafting seen in recent years in the United States has not been met with an equal gain in knowledge of the perils of this anatomic territory. The purpose of this study was to identify anatomic landmarks that can be readily used by surgeons to identify the takeoff of the superior and inferior gluteal veins. Method: Six fresh cadaveric gluteal specimens were dissected at the University of Louisville anatomy laboratory. A question mark incision was made for exposure, followed by identification of the sciatic nerve in the proximal thigh. This was traced retrograde to the sciatic forearm. The piriformis muscle was identified dividing the foreman into superior and inferior portions, which corresponded to the takeoff of the superior and inferior gluteal vessels, respectively. The distance of the gluteal vessels from the one-third point of a line from the mid-sacrum to the greater trochanter was measured. Result: Our cadaveric dissection series demonstrated that the superior and inferior gluteal veins were on average 3.28 cm (2-5.9 cm) and 1.25 cm (0-3.5 cm) away from the point one third the distance from the mid-sacral border to the greater trochanter. Conclusion: Themid-sacrumand the trochanter of the femur are the anatomic landmarks used to identify the large gluteal vein trunks. Understanding the location and trajectory of these deep gluteal structures with use of readily identifiable landmarks may assist surgeons in avoiding inadvertent injection of fat to these veins during fat grafting. [ABSTRACT FROM AUTHOR]