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Previous reports suggest that a complex microbiome exists within the female human breast that might contribute to breast cancer etiology. The purpose of this pilot study was to assess the variation in microbiota composition by breast side (left versus right) within individual women and compare the microbiota of normal and breast tumor tissue between women. We aimed to determine whether microbiota composition differs between these groups and whether certain bacterial taxa may be associated with breast tumors. Bilateral normal breast tissue samples (n = 36) were collected from ten women who received routine mammoplasty procedures. Archived breast tumor samples (n = 10) were obtained from a biorepository. DNA was extracted, amplified, and sequenced. Microbiota data were analyzed using QIIME and RStudio. The most abundant phyla in both tumor and normal tissues were Bacteroidetes, Firmicutes, Proteobacteria, and Actinobacteria. There were statistically significant differences in the relative abundance of various bacterial taxa between groups. Alpha diversity (Simpson’s index) was significantly higher in normal compared to tumor samples (0.968 vs. 0.957, p = 0.022). Based on unweighted UniFrac measures, breast tumor samples clustered distinctly from normal samples (R2 = 0.130; p = 0.01). Microbiota composition in normal samples clustered within women (R2 = 0.394; p = 0.01) and by breast side (left or right) within a woman (R2 = 0.189; p = 0.03). Significant differences in diversity between tumor and normal tissue and in composition between women and between breasts of the same woman were identified. These results warrant further research to investigate the relationship between microbiota and breast cancer.

Purpose Nerve transfers for peripheral nerve injuries can result in variable outcomes. We investigated the neuroprotective effect of epineurial lidocaine injection in the donor nerve prior to transection, with the hypothesis that proximal axon loss would be decreased with consequent increased neuroregeneration and functional recovery. Methods A rat sciatic nerve model was used with 4 intervention groups: (1) lidocaine; (2) lidocaine/calcium gluconate (CG); (3) CG; or (4) saline (control). Behavioral testing and qualitative and quantitative histological evaluation was performed at 8 and 12 weeks. Histological assays included transmission electron microscopy, retrograde fluorogold labeling, and whole mount immunostaining. Results Functional assessments through the sciatic functional index and Basso, Beattie, and Bresnahan scale showed a statistically significant increase in recovery at 8 and 12 weeks with lidocaine treatment. Significantly higher axonal counts were obtained in the lidocaine-treated groups. Fragmentation and increased myelin damage was present in the CG and saline groups. Retrograde fluorogold labeling showed a statistically significant increase in the number of L4-6 dorsal root ganglion neurons in the lidocaine-treated groups. Whole mount immunostaining identified extension of the axonal growth cone past the nerve coaptation site in lidocaine-treated groups, but not in CG and saline groups. Conclusions Our results suggest that epineurial lidocaine injection prior to donor nerve transection for nerve transfer has a neuroprotective effect, resulting in increased proximal axon counts and improved functional recovery. Clinical relevance These findings may have direct clinical application because epineurial lidocaine can be used in surgery as a simple and inexpensive intervention for promoting improved clinical outcomes after nerve transfer.

BACKGROUND Diabetes mellitus is a well-known risk factor for infection after trigger finger (TF) injection and/or release. However, the effect of preoperative hypoglycemia before TF injection or release is currently unknown. The purpose of this study is to determine the effects of preoperative hypoglycemia on infection incidence after TF injection or release. METHODOLOGY A retrospective cohort review between 2007 and 2015 was conducted using a national private payer database within the PearlDiver Supercomputer. Preoperative, fasting, glucose levels were collected for each patient, and these ranged from 20 to 219 mg/dL. Surgical site infection (SSI) rates were determined using International Classification of Diseases, Ninth Revision codes. RESULTS The query of the PearlDiver database returned 153,479 TF injections, of which 3479 (2.27%) and 6276 (4.09%) had infections within 90 days and 1 year after procedure, respectively. There were 70,290 TF releases identified, with 1887 (2.68%) SSIs captured within 3 months after surgery and 3144 (4.47%) within 1 year after surgery. There was a statistically significant increase in SSI rates in patients with hypoglycemia within 90-day (P = 0.006) and 1-year (P < 0.001) time intervals post-TF injection. Likewise, a statistically significant increase in SSI rate in patients with hypoglycemia undergoing TF release within 1 year after release was seen (P = 0.003). CONCLUSIONS Hypoglycemia before TF injection or release increases the risk for SSI. Tight glycemic control may be warranted to mitigate this risk. Further studies are needed to investigate the effect of hypoglycemia as an independent risk factor for SSI.

We report the results of ten consecutive patients who had correction of an elbow flexion contracture of greater than 30° in brachial plexus birth injury using a modified Outerbridge-Kashiwagi procedure. All patients had minimum 23-month follow-up. Pre- and post-operative elbow range of motion and DASH scores were recorded in all patients. The operative technique for the procedure and post-operative course is discussed. Surgery was supplemented by botulinum toxin injection into the biceps brachii muscle in most cases. The average age at surgery was 14 years 10 months. The initial plexus lesion was global in eight patients and upper in two. Pre-operative flexion contractures averaged 51° (range 35 to 60) and post-operative averaged 21° (range 15 to 30). Of these patients, one had no change in active flexion, four had loss of active flexion, and five had gain of active flexion. All ten patients were satisfied with their results and stated that they would recommend the procedure to other patients.Level of evidence: IV

Highlights • Myoepithelial carcinoma of the vulva and epithelioid sarcoma has overlapping histological, immunohistochemical and genetic features. • Similarities between two diagnoses in aggressive vulvar cancer should be noted as a sarcoma-based chemotherapy regimen should be considered. • We recommend immediate surgical resection with bilateral superficial and deep inguinal lymph node dissections in these aggressive cancers. • Identification of SMARCB1-deficiency trials of targeted therapies such as EZH2 inhibitors which show promise in halting further progression., Introduction Myoepithelial carcinoma and proximal-type epithelioid sarcoma of the vulva are two rare malignancies with known aggressive behavior. In addition to a similar clinical course, these two disease entities also have significant histologic and pathologic overlap. Given the rarity of these malignancies, there is limited literature on the appropriate treatment regimen. Nevertheless, there is a consensus that early surgical resection is beneficial in both cases. Presentation We present a case of a patient who was initially diagnosed with myoepithelial carcinoma of the vulva with a differential later expanded to include possible epithelioid sarcoma. Discussion We demonstrate the importance in early identification of a SMARCB1 deficiency. Additionally, we suggest an appropriate treatment regimen for these patients going forward. Specifically, we encourage consideration of bilateral superficial and deep inguinal lymphadenectomies. Furthermore, sarcoma based chemotherapy regimens in the appropriate clinical setting may be beneficial in treating SMARCB1 deficient tumors. Additionally, there are now clinical trials involving EZH2 Inhibitors which may offer benefit for similar patients going forward. Conclusion This case highlights the difficulty in making a definitive diagnosis, and the importance in identifying a SMARCB1 deficiency as it will affect treatment options and may allow for enrollment in ongoing clinical trials.

Purpose Staged separation of 3- and 4-finger syndactyly is commonly performed owing to concerns about vascular supply to the central digit and availability of flap skin. We performed single-stage separation of patients with incomplete syndactyly of multiple digits with adjacent contiguous dorsal gullwing flaps and avoided skin grafts in the majority of cases. Methods Seventy-four webs of 31 patients with more than 2-finger incomplete syndactyly were included. Median age at surgical separation was 12 months (range, 5–123 months). All cases were incomplete syndactyly that did not extend to the fingernail level, with no bony involvement. A dorsal gullwing flap was used for all cases, which reconstructed the interdigital webs and partly covered the lateral side of the proximal phalanx. The technique relies on perfusion of the flap through the dorsal metacarpal artery perforator to aid flap mobility and double radial and ulnar z-plasties on each side of the flap to aid flap advancement. Skin grafts were needed if there were any remaining skin defects. Results In 30 of 31 cases, a single-stage procedure was accomplished. One case was staged owing to abnormal digital arterial anatomy found on exploration. No skin graft was required in 21 out of 31 patients (67.7%). Median postoperative follow-up was 12 months (range, 6–36 months). All finger web depths were normal or slightly deepened. Conclusions One-stage separation for 3- and 4-finger syndactyly with a dorsal gullwing flap is feasible and safe as long as at least 1 proper digital artery is preserved in each finger. The need for skin grafting is minimized. Type of study/level of evidence Therapeutic IV.

Background Upper extremity soft tissue defects with complete circumferential involvement are not common. Coupled with the unique anatomy of the upper extremity, the underlying etiology of such circumferential soft tissue defects represent additional reconstructive challenges that require treatment to be tailored to both the patient and the wound. The aim of this study is to review the various options for soft tissue reconstruction of complete circumferential defects in the upper extremity. Methods A literature review of PubMed and MEDLINE up to December 2016 was performed. The current study focuses on forearm and arm defects from the level at or proximal to the wrist and were assessed based on Tajima's classification (J Trauma 1974). Data reviewed for analysis included patient demographics, causality, defect size, reconstructive technique(s) employed, and postoperative follow-up and functional outcomes (when available). Results In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 14 unique articles were identified for a total of 50 patients (mean=28.1 years). Underlying etiologies varied from extensive thermal or electrical burns to high impact trauma leading to degloving or avulsion, crush injuries, or even occur iatrogenically after tumor extirpation or extensive debridement. Treatment options ranged from the application of negative pressure wound dressings to the opposite end of the spectrum in hand transplantation. Conclusions With the evolution of reconstructive techniques over time, the extent of functional and aesthetic rehabilitation of these complex upper extremity injuries has also improved. The proposed management algorithm comprehensively addresses the inherent challenges associated with these complex cases.

Summary Introduction Reconstruction of Wassel IV-D radial polydactyly is challenging and requires a custom strategy dependent on the relative size and shape of the radial and ulnar duplicates. Herein, we describe a technique using a boot-shaped neurovascular island flap and review our outcomes. Methods Ninety-one consecutive patients had reconstruction with a boot-shaped neurovascular island flap. The flap was dissected out from the thumb to be removed. Specific flap modifications were inclusion of the lateral nail fold, Bruner incisions dorsally and volarly to reduce scarring at the interphalangeal (IP) joint and also complete mobilization of the island flap on its pedicle to allow easier inset. A flexor pollicis longus and extensor tendon rebalancing technique was used to correct the deviation of the reconstructed thumb IP joint. Results All boot-shaped neurovascular island flaps survived with good contour, shape, and symmetry. The average follow-up period was 25 months (range 6–60 months). Using the Japanese Society for Surgery of the Hand (JSSH) score for classification of outcomes, seven cases were classified as excellent and 84 cases as good. The median JSSH score was 18. The median Kapandji score for opposition was 9 (range 8–10). Conclusion Using a boot-shaped neurovascular island flap completely mobilized on its pedicle with a custom strategy for each radial duplicate, good outcomes can be achieved in reconstruction of Wassel IV-D radial polydactyly. Level of evidence Therapeutic Level IV

Contractures from burns or other trauma generally manifest as discrete areas of skin deficiency or localized scar bands in the hand, and are treated successfully with release and resurfacing of the affected area. We report a case of generalized bilateral skin tightness in the hand from severe childhood burns, with no obvious localized area of contracture, manifesting with pain and numbness when making a fist and with certain activities. This was treated with release and resurfacing of the first webspace with bilateral free lateral arm flaps as well as endoscopic carpal tunnel release, resulting in increased laxity of skin throughout both hands, and resolution of dynamic symptoms with activity.

Scapholunate ligament (SLL) injuries are a common cause of wrist pain and instability. Treatment of SLL injuries requires intricate understanding of wrist anatomy and biomechanics. Mindful physical exam and appropriate diagnostic studies can orient the surgeon to the defined stage of injury. Review of the literature on each treatment by stage can prepare the upper extremity surgeon to provide the best evidence-based care. The optimal management of SLL injuries should result in a stable, painless wrist.

Background: Cubital tunnel syndrome (CUT) is the second most common peripheral neuropathy with an annual incidence of 24.7 per 100 000, affecting nearly twice as many men as women. With increasing focus on cost-effectiveness and cost-containment in medicine, a critical understanding of utilization of health care resources for open and endoscopic approaches for cubital tunnel release is of value. The purpose of this study was to evaluate the costs and utilization trends of open and endoscopic cubital tunnel release. Methods: We performed a retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, Indiana) for procedures performed from 2005 to 2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate were evaluated. Results: Our query returned 262 104 patients with CUT, of which 69 378 (26.5%) and 4636 (1.8%) were surgically managed with open and endoscopic release respectively. Average charges were higher in endoscopic release ($3798) than open release ($3197) while reimbursements were higher in open releases ($1041) than endoscopic release, ($866). Both were performed most commonly in the

Purpose: The purpose of this pilot study was to assess the differences in breast tissue microbiota composition by breast side (left versus right) within an individual woman and compare the microbiota of healthy and breast tumor tissue between women. We further aimed to determine whether certain bacterial taxa may be associated with breast tumors. Methods: Bilateral healthy breast tissue samples (n=36) were collected from ten women who received routine mammoplasty procedures at the University of Florida Department of Surgery. Archived breast tumor samples (n=10) were obtained from an established biorepository. Bacterial DNA was extracted from tissues, amplified via polymerase chain reaction (PCR), and sequenced on the Illumina MiSeq platform. Microbiota data were analyzed using QIIME and RStudio. Results: The most abundant phyla in both tumor and healthy tissues were Bacteroidetes, Firmicutes, Proteobacteria, and Actinobacteria. A total of 38 operational taxonomic units (OTUs) were found to be significantly different in terms of differential abundance between tumor and healthy tissues (absolute effect size range: 0.761-3.98). The OTUs with the largest absolute effect size associated with higher relative abundance in breast tumors were of Flavobacterium species (R2=3.98), Acinetobacter species (R2=3.64), [Mogibacteriaceae] family (R2=3.34), and Clostridiales order (R2=3.21). Alpha diversity (Shannon Diversity Index) was similar in healthy and tumor tissue (4.98 vs. 4.84; p=0.350). Based on unweighted UniFrac measures, breast tumor samples clustered distinctly from healthy samples (R2=0.10; p=0.001). Microbiota composition in healthy samples clustered within women (R2=0.20; p=0.012) and by breast side (left or right) within a woman (R2=0.36; p=0.001). Conclusion: We identified significant differences in microbiota composition between women and between breasts of the same woman. These results warrant further investigation to elucidate the potential relationship between breast tissue microbiota and breast cancer. Citation Format: Emily M. Klann, Jessica M. Williamson, Massimiliano S. Tagliamonte, Maria Ukhanova, Jaya Ruth Asirvatham, Harvey Chim, Lusine Yaghjyan, Volker Mai. Microbiota composition in bilateral healthy breast tissue and breast tumors [abstract]. In: Proceedings of the AACR Special Conference on the Microbiome, Viruses, and Cancer; 2020 Feb 21-24; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2020;80(8 Suppl):Abstract nr B31.

Purpose To investigate anatomic abnormalities causing a congenital ulnarly deviated thumb at the distal phalanx. Methods A total of 122 children with 157 congenital ulnarly deviated thumbs at the distal phalanges were reviewed, including those with isolated deformity or polydactyly. We analyzed the incidence and characteristics of the underlying anatomic abnormalities as well as the differential diagnoses. Results Three main causes of an ulnarly deviated thumb were observed. Abnormal hypertrophic epiphyses were found in 96 thumbs. An extra phalanx lying between the normal proximal and distal phalanges was found in 59 thumbs. A previously undescribed cause was found in 2 thumbs with Wassell IV polydactyly, in which an obliquely angled articular surface of the proximal phalanx manifested with ulnar deviation at the interphalangeal joint. Radiographic analysis showed that in cases with abnormal epiphyses, the epiphysis was in good apposition and good alignment with its relevant distal phalanx; the distance from the abnormal epiphysis to the phalanx was usually less than 1 mm. In contrast, in cases of extra phalanges, the distance from the epiphysis to the phalanx averaged more than 2 mm and there was poor apposition between the distal phalanx and the extra bone. Conclusions Abnormal hypertrophic epiphysis and triphalangeal thumb are the 2 main causes of a congenital ulnarly deviated thumb. A distance of more than 2 mm between the abnormal bone and the distal phalanx suggests a triphalangeal thumb. Type of study/level of evidence Therapeutic IV.

OBJECTIVEThe epidemiology of carpal tunnel syndrome (CTS) has been extensively researched. However, data describing the economic burden of CTS is limited. The purpose of this study was to quantify the disease burden of CTS and determine the economic benefit of its surgical management.METHODSThe authors utilized the PearlDiver database to identify the number of individuals with CTS in the Medicare patient population, and then utilized CPT codes to identify which individuals underwent surgical management. These data were used to calculate the total number of disability-adjusted life years (DALYs) associated with CTS. A human capital approach was employed and gross national income per capita was used to calculate the economic burden.RESULTSFrom 2005 to 2012 there were 1,500,603 individuals identified in the Medicare patient population with the diagnosis of CTS. Without conservative or surgical management, this results in 804,113 DALYs without age weighting and discounting, and 450,235 DALYs with age weighting and a discount rate of 3%. This amounts to between $21.8 and $39 billion in total economic burden, or $2.7–$4.8 billion per year. Surgical management of CTS has resulted in the aversion of 173,000–309,000 DALYs. This has yielded between $780 million and $1.6 billion in economic benefit per year. Endoscopic carpal tunnel release provided between $11,683 and $23,186 per patient at 100% success while open carpal tunnel release provided between $10,711 and $22,132 per patient at 100% success. The benefit-cost ratio at its most conservative is 2.7:1, yet could be as high as 6.9:1.CONCLUSIONSCTS is prevalent in the Medicare patient population, and is associated with a large amount of economic burden. The surgical management of CTS leads to a large reduction in this burden, yielding extraordinary economic benefit.

Background: Most brachial plexus birth injuries (BPBIs) are caused by traction on the brachial plexus during a difficult delivery. Fortunately, the possibility of complete recovery from such an incident is relatively high, with only 10% to 30% of patients having prolonged and persistent disability. These patients have muscle imbalances and co-contractions typically localized around the shoulder and elbow. These imbalances and co-contractures cause abnormal motor performances and bone/joint deformities. Typically, physical/occupational therapies are the conventional therapeutic modalities but are often times inadequate. Botulinum toxin A (BTX-A) injections into targeted muscles have been used to combat the muscular imbalances and co-contractions. Methods: With compliance to PRISMA guidelines, a systematic review was performed to identify studies published between 2000 and 2017 that used BTX-A to treat neonatal brachial plexus palsies. Results: Ten studies were included, involving 325 patients. Three groups of indications for the use of BTX-A were identified: (1) internal rotation/adduction contracture of the shoulder; (2) elbow flexion lag/elbow extension lag; and (3) forearm pronation contracture. Conclusions: The included studies show an overall beneficial effect of BTX-A in treating co-contractures seen in patients with BPBI. Specifically, BTX-A is shown to reduce internal rotation/adduction contractures of the shoulder, elbow flexion/extension contractures, and forearm pronation contractures. These beneficial effects are blunted when used in older patients. Nevertheless, BTX-A is a useful treatment for BPBIs with a relatively low-risk profile.

Objectives Diabetic patients undergoing surgery are known to have a higher risk for infection. However, current literature does not adequately investigate the effects of preoperative hypoglycemia or hyperglycemia on postoperative infection risk. Methods A retrospective review of a national private payer database within the PearlDiver Supercomputer application (Warsaw, IN) for patients undergoing breast reconstruction with implant/expander (BR) was conducted. These patients were identified by Current Procedural Terminology (CPT) and International Classification of Disease (ICD-9) ninth revision codes. Glucose ranges were identified by filtering for Logical Observation Identifiers Names and Codes ranging from 25 to 219 mg/dL, in 15 mg/mL increments. Patients with preexisting diabetes diagnoses were excluded. These patients were longitudinally tracked for infection at the 90 d and 1-y postoperative period using ICD-9 codes. Results The search query yielded 13,237 BR procedures with preoperative glycemic levels ranging from 25 to 219 mg/mL. Most procedures (34.6%) were performed on patients with preoperative glycemic levels ranging from 70 to 99 mg/dL. Of the total procedures performed (n = 13,237), 19.4% (n = 2564) resulted in infections documented at the 90-d interval, and 24.8% (n = 3285) resulted in infections documented at the 1-y interval. BR patients within the 40-54 mg/dL range had the highest rate of infection (90 d: 30.1%; 1 y: 53.4%). There was a statistically higher incidence of infection among patients with preoperative hypoglycemia ( Conclusions The incidence of infection remains high in preoperatively hyperglycemic patients undergoing breast reconstruction procedures. However, our results show that preoperatively hypoglycemic patients also have an increased incidence of infection.

OBJECT Transfer of the triceps motor branch has been used for treatment of isolated axillary nerve palsy in the adult population. However, there are no published data on the effectiveness of this procedure in the pediatric population with traumatic injuries. The authors reviewed demographics and outcomes in their series of pediatric patients who underwent this procedure. METHODS Six patients ranging in age from 10 to 17 years underwent triceps motor branch transfer for the treatment of isolated axillary nerve injuries between 4 and 8 months after the inciting injury. Deltoid muscle strength was evaluated using the modified British Medical Research Council (MRC) grading system. Shoulder abduction at last follow-up was measured. RESULTS The mean duration of follow-up was 38 months. The average postoperative MRC grading of deltoid muscle strength was 3.6 ± 1.3. The median MRC grade was 4. One patient who did not achieve an MRC grade of 3 suffered multiple injuries from high-velocity trauma. Unlike in the adult population, age, body mass index of the patient, and delay from injury to surgery were not significant factors affecting the outcome of the procedure. CONCLUSIONS In the pediatric population with traumatic injuries, isolated axillary nerve injury treated with triceps motor branch transfer can result in good outcomes.

Brachial plexus birth injuries are rare, with treatment and follow-up often required from infancy until skeletal maturity. We review complications that may occur related to primary nerve surgery or secondary musculoskeletal procedures, and discuss how these may be avoided.

Background: Intravenous glomus tumors are extremely rare. Methods: We report a patient with an intravenous glomus tumor within a venous aneurysm misdiagnosed as a neuroma of the lateral antebrachial cutaneous nerve, based on clinical exam, electrodiagnostic studies, and findings on a magnetic resonance imaging neurogram. Results: After surgical resection, the patient’s symptoms, including pain and localized hypersensitivity, totally resolved. Conclusions: This case illustrates 2 important points. First, unlike extradigital glomus tumors, magnetic resonance imaging is not reliable in diagnosing intravenous glomus tumors. Second, in the presence of chronic localized neuroma type pain and sensitivity in the upper limb without a clear cause, an extradigital cutaneous or intravenous glomus tumor must be considered in the differential diagnosis.

Background In the past 130 years, the temporalis muscle flap has been used for a variety of different indications. In this age of microsurgery and perforator flaps, the temporalis muscle flap still has many useful applications for craniofacial reconstruction. Methods Three hundred sixty-six temporalis muscle flaps were performed in a single center between 1978 and 2012. The authors divided the cases into two series-before and after 1994-because, after 1994, they started to perform free flap reconstructions, and indications for reconstruction with a temporalis muscle flap were changed RESULTS:: In the series after 1994, flaps were most commonly used for reconstruction of defects in the maxilla, mandible, and oropharynx, in addition to facial reanimation and filling of orbital defects. Complications included total flap necrosis (1.6 percent) and partial flap necrosis (10.7 percent). The rate of material extrusion at the donor site decreased after porous polyethylene was uniformly used for reconstruction from 17.1 to 7.9 percent. Conclusions The pedicled temporalis muscle flap continues to have many applications in craniofacial reconstruction. With increasing use of free flaps, the authors' indications for the pedicled temporalis muscle flap are now restricted to (1) orbital filling for congenital or acquired anophthalmia; (2) filling of unilateral maxillectomy defects; and (3) facial reanimation in selected cases of facial nerve palsy. Clinical question/level of evidence Therapeutic, IV.

Purpose To report our technique and experience with use of free functioning muscle transfer (FFMT) in reconstruction of traumatic brachial plexus injuries (BPIs) in children as well as its complications and outcomes. Methods Twelve patients with complete BPI underwent FFMT for reconstruction between 2000 and 2012. Eight had single-stage gracilis transfer for restoration of elbow flexion, and 4 children had double free gracilis muscle transfer for restoration of elbow flexion and prehension. Mean duration of follow-up was 27 months (range, 14–55 mo). Results Eleven out of 12 patients achieved at least M3 elbow flexion, with 8 patients achieving M4 or greater elbow flexion. Eight of 12 patients had nerve transfers to the musculocutaneous nerve. Mean active elbow arc of motion was 79° (range, 30°–130°). Two patients aged 8 and 11 years with open growth plates developed elbow joint contractures, which limited range of motion, but they recovered M4 and M5 elbow flexion strength. Conclusions FFMTs can result in good outcomes following reconstruction for traumatic BPI. The use of FFMT should be carefully considered in children prior to skeletal maturity because of the risk of the development of an elbow flexion contracture. Type of study/level of evidence Therapeutic IV.

Reconstruction of sacrectomy defects following ablative surgery remains a challenge, with high complication rates in the reported literature. The size of the defect is the primary consideration for flap choice; however, the cause of intra-abdominal and flap complications remains unclear. The aim of the study was to evaluate our results for sacrectomy flap reconstruction in order to determine predictive or protecting factors for complications.A 13-year retrospective review was performed of all patients who had reconstruction for partial and total sacrectomy defects at the Mayo Clinic in Rochester, MN, USA. Demographics, flap choice, and complications were analyzed. Multivariate analysis was used to determine factors causing flap and intra-abdominal complications.Fifty-four patients underwent reconstruction. Partial sacrectomy was performed in 38 (70.4%) patients, while total sacrectomy was performed in 16 (29.6%) patients. The average wound defect volume was 2136 cm(3) (range 196-13,980 cm(3)). Flaps used included gluteal (n = 15; 27.8%), rectus abdominis myocutaneous (RAM) (n = 37; 68.5%), and combined gluteal/RAM (n = 2; 3.7%). Obesity was significantly associated with intra-abdominal complications (p 0.05) while preoperative radiotherapy and chemotherapy were not. Flap and wound healing complications were not significantly associated with any factors.Gluteal advancement and vertical RAM or transverse RAM flaps are both reliable options for reconstruction of sacrectomy defects. The use of acellular dermal matrix (ADM) for reconstructing the posterior abdominal wall provides a barrier between the intra-abdominal contents and flap, preventing bowel adhesions/obstruction and fistulas as well as prevents sacroperineal hernia.

Summary Background Surgical correction of craniosynostosis aims to remodel the cranial vault to achieve a morphology approaching that of age-matched norms. However, current surgical technique is highly subjective and based largely on the surgeon's artistic vision in creating a normal head shape. Here, we present our technique and report our experience with the use of virtual surgery using computer-assisted design (CAD)/computer-assisted manufacturing (CAM) techniques to create a prefabricated template for the planning of osteotomies and the placement of bone segments, to achieve standardised, objective and precise correction of craniosynostosis. Methods Four patients who underwent cranial vault remodelling (CVR; three metopic synostosis and one sagittal synostosis) underwent virtual surgical planning (VSP) preoperatively using CAD/CAM techniques. VSP allows pre-planning of osteotomies to achieve the desired cranial vault shape. Surgical osteotomies and placement of bone segments were performed intra-operatively based on prefabricated templates. Results All patients demonstrated markedly improved head shape postoperatively. One patient developed a subdural haematoma 6 weeks postoperatively subsequent to a fall where he hit his head. The haematoma was drained and a soft spot was present in that location 3 months postoperatively. Conclusion The use of virtual surgery and prefabricated cutting guides allows for a more precise and rapid reconstruction. Surgical osteotomies are pre-planned and rapidly performed using a template, and precise placement of calvarial bone segments is achieved without the need for subjective assessment of the desired calvarial shape. In addition, patients and families have a significantly better understanding of the disease process and anticipated surgery preoperatively with the visualisation achieved through virtual surgery. This results in better alignment of hopes and expectations between the parents and surgeons.

This chapter describes in detail the surgical steps for performing an incision, drainage and irrigation for suppurative flexor tenosynovitis. The operative note has been generalized so that it can be applied to various digits of the hand with appropriate modifications. The approach should allow for incision and drainage of the affected digit as well as placement of an apparatus amenable for postoperative irrigation of the tendon sheath. Indications, surgical steps, postoperative care, an operative dictation template, and suggested readings/references are included.

This chapter describes in detail the surgical steps for performing a dorsal wrist ganglion cyst excision. The approach allows for an operative alternative to unsuccessful conservative management for dorsal wrist ganglion cysts or cysts unamenable to simple aspiration. Indications, surgical steps, postoperative care, an operative dictation template, and suggested readings/references are included.

Stenosing tenosynovitis (aka “trigger finger”) is a common condition in adults, with “trigger thumb” commonly occurring in children. These conditions are due to impairment of the normal sliding of the digit’s flexor tendon thru the A-1 pulley (resulting from flexor tendon inflammation). This condition can be managed nonsurgically, usually with splinting, or corticosteroid injection. If indicated, trigger digit can be managed via surgically releasing the A-1 pulley. In long-standing and severe tenosynovitis, an additional step of tenosynovectomy may be indicated. This chapter aims to provide a brief overview of the indications, possible complications, and essential steps involved in the open surgical release of trigger thumb. It also provides an example of the operative dictation and relevant coding information.

Surgical management of carpal tunnel syndrome (CTS) is performed with an open or endoscopic approach. Current literature suggests that the endoscopic approach is associated with higher costs and a steeper learning curve. This study evaluated the billing and utilization trends of both approaches.A retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, IN) was performed for patients undergoing open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR) from 2005-2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate (CAGR) were evaluated.Our query returned 1,500,603 carpal tunnel syndrome patients, of which 507,924 (33.8%) and 68,768 (4.6%) were surgically managed with OCTR and ECTR respectively (remainder treated conservatively). Compound annual growth rate was significantly higher in ECTR (5%) than OCTR (0.9%; P 0.001). Average charges were higher in OCTR ($3820) than ECTR ($2952), whereas reimbursements were higher in ECTR (mean $1643) than OCTR (mean $1312). Both were performed most commonly in the age range of 65-69 y, females, and southern geographic region.ECTR is growing faster than OCTR in the Medicare population. Contrary to previous literature, our study shows that ECTR had lower charges and reimbursed at a higher rate than OCTR.

Background Craniotomies for trauma are associated with a significant risk of wound complications. We report a case in which a chronic nonhealing draining sinus was caused by an ectopic epidermal lining deep to the craniotomy bone flap, adherent to the underlying dura. Case Description A 61-year-old man was examined for a 3-year-old, nonhealing scalp wound resulting after a traumatic brain injury. His initial surgery consisted of an intracranial hematoma evacuation through a temporoparietal craniotomy; this was complicated by wound dehiscence and a chronic sinus draining clear fluid that did not resolve with antimicrobial therapy. Intraoperatively, a layer of hair-bearing skin adherent to the dura was found deep to the entirety of the previous bone flap. There was no dura tear or overt cerebrospinal fluid leak. This necessitated removal of the skin over the dura as well as the overlying bone flap. The resultant defect was reconstructed with a titanium mesh and hydroxyapatite cranioplasty, with a scalp rotation flap for coverage of the cutaneous defect. Pathology confirmed skin with intact adnexal structures. Conclusion This case demonstrates that it is possible for hair-bearing skin to grow directly on dura, deep to an intact craniotomy bone flap. With a chronic draining sinus in the absence of computed tomography and magnetic resonance imaging findings, this should be part of the differential diagnosis.

The purpose of this article is to report the authors' experience with the use of the modified great toe wraparound flap with preservation of a plantar triangular flap for reconstructing degloving injuries of the thumb and fingers.Between 2007 and 2012, 31 patients underwent reconstruction with 37 flaps. Twenty-seven patients underwent reconstruction with 31 flaps for a degloved thumb and fingers, and four patients underwent reconstruction with six flaps for degloved fingers only. A modified great toe wraparound flap with second toe medial toe hemipulp flap on a common pedicle was used for reconstruction of degloved fingers in four patients. Twelve patients had long-term follow-up, with a mean duration of 5 years (range, 2 to 8 years).All flaps survived. The contour of the reconstructed digits was similar to the contralateral one. In patients with long-term follow-up, mean two-point discrimination of reconstructed digits was 6.2 mm (range, 3 to 8 mm). Mean Disabilities of the Arm, Shoulder and Hand questionnaire score was 0.8 ± 1.0. Mean Michigan Hand Outcomes Questionnaire score was 87.3 ± 3.7. Mean Foot and Ankle Disability Index score was 95.5 ± 2.7. The width of the preserved plantar triangular flap expanded from 35 percent to 67 percent of the width of the great toe and completely covered the weight-bearing area.Reconstruction of degloved thumb and fingers with a modified great toe wraparound flap, preserving a plantar triangular flap, results in excellent contour and functional outcome. Donor-site morbidity in the foot was minimal.Therapeutic, IV.

Summary Background and aim Radial forearm phalloplasty is accompanied by high rates of fistula formation. We examined the effect of placing a pedicled gracilis myofascial flap around the urethral anastomosis at the time of radial forearm flap transfer on the development of postoperative urethrocutaneous fistula. Methods Fifteen patients underwent phalloplasty with urethroplasty between June 2012 and October 2015, and they met the inclusion and exclusion criteria for the study. We retrospectively reviewed patients' medical records and extracted patient demographic data, prelamination technique used (mucosa, skin graft, both, or neither), and whether or not a gracilis myofascial flap was harvested at the time of flap transfer and used to reinforce the native-neourethral anastomosis. The chi-squared test was used to evaluate the association between the presence of a gracilis flap and fistula formation. Results Four patients received a gracilis flap as part of their primary phalloplasty operation. None of these patients developed a fistula. Eleven patients did not receive a gracilis flap at the time of initial surgery and seven developed a fistula. Discussion In our patient series, inclusion of a pedicled myofascial gracilis flap at the time of radial forearm phalloplasty with urethroplasty was associated with an absence of fistula formation. Therefore, we have since made inclusion of this flap a standard practice for all transmales undergoing phalloplasty with urethroplasty.

Proximal row carpectomy (PRC) is an established and widely used procedure for treatment of degenerative conditions of the wrist. The procedure involves excision of the scaphoid, lunate, and triquetrum, with formation of a new articulation between the lunate fossa of the distal radius and the proximal aspect of the capitate. Relief of pain and preservation of wrist range of motion and grip strength have been demonstrated. Long-term studies have shown the durability of PRC as a salvage procedure for treatment of advanced Kienbock’s disease. In the presence of full-thickness cartilage defects of the proximal capitate or lunate fossa of the distal radius, an interposition flap from the dorsal capsule has been recommended as an adjunct to PRC to allow for wrist salvage in these complex cases; unfortunately long-term studies have been inconclusive to determine the benefits of capsular interposition in the presence of cartilage wear and arthritis in patients with Kienbock’s disease. Careful patient selection is critical for successful outcomes when choosing PRC. Optimal results are obtained in patients older than 40 years of age who do not engage in heavy manual labor.

Purpose Proximal row carpectomy is a well-established technique for the management of wrist arthritis; however, patient selection and long-term durability of proximal row carpectomy is still a matter of controversy. Hence, we conducted a systematic review of the English literature to determine the best evidence on long-term outcomes following proximal row carpectomy. Methods A MEDLINE search using the term “proximal row carpectomy” was performed. A total of 192 studies were identified. All studies with 10 or more years of follow-up were included in the review. Data extracted included patient demographics, indications for surgery, previous surgery, outcome assessment, and information on complications and failures. Results A total of 147 patients from six studies met the inclusion criteria and were included in the study. The majority of patients were male and involved in manual labor. There was no significant difference between the preoperative and long-term postoperative motion. The weighted mean for postoperative grip strength was 68.4% compared with the contralateral side. Disabilities of the arm, shoulder, and hand; patient-rated wrist examination; and Mayo wrist scores were comparable to those reported for four-corner arthrodesis. There were 21 failures (14.3%) requiring re-operation. Failures were not associated with a specific preoperative diagnosis but distributed among patients with Kienbock disease, scaphoid nonunion advanced collapse, and scapholunate advanced collapse arthritis. Conclusions This systematic review confirms the long-term durability of proximal row carpectomy when used for the treatment of wrist arthritis. Although radiocapitate arthritis develops over time in most patients, the clinical significance of this finding is undetermined and does not necessarily correlate with failure of proximal row carpectomy. Poorer long-term outcomes are likely to result in patients engaged in heavy manual labor, whereas better outcomes may be obtained in patients undergoing proximal row carpectomy for trauma or earlier-stage Kienbock disease.

Objective:To investigate the mechanism of propranolol on regression of infantile hemangiomas.Background:Propranolol has been found to be effective in treatment of severe hemangiomas of infancy. However, its mechanism of action is as yet unknown.Methods:Cultured proliferating and involuting hemangiom

This study was designed to compare the efficacy of the transpalpebral versus endoscopic approach to decompression of the supraorbital and supratrochlear nerves in patients with frontal migraine headaches.The medical charts of 253 patients who underwent surgery for frontal migraine headaches were reviewed. These patients underwent either transpalpebral nerve decompression (n = 62) or endoscopic nerve decompression (n = 191). Preoperative and 12-month or greater postoperative migraine frequency, duration, and intensity were analyzed to determine the success of the surgeries.Forty-nine of 62 patients (79 percent) in the transpalpebral nerve decompression group and 170 of 191 patients (89 percent) who underwent endoscopic nerve decompression experienced a successful outcome (at least a 50 percent decrease in migraine frequency, duration, or intensity) after 1 year from surgery. Endoscopic nerve decompression had a significantly higher success rate than transpalpebral nerve decompression (p0.05). Thirty-two patients (52 percent) in the transpalpebral nerve decompression group and 128 patients (67 percent) who underwent endoscopic nerve decompression observed elimination of migraine headaches. The elimination rate was significantly higher in the endoscopic nerve decompression group than in the transpalpebral nerve decompression group (p0.03).Endoscopic nerve decompression was found to be more successful at reducing or eliminating frontal migraine headaches than transpalpebral nerve decompression and should be selected as the first choice whenever it is anatomically feasible.Therapeutic, III.

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons’ perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons’ perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Introduction Postpriapism erectile dysfunction in patients with sickle cell disease is a particularly devastating condition. Where penile implants have failed, there is no good surgical alternative at present. Free tissue transfer is fraught with risks in patients with sickle cell disease and are not the best option for treatment. Aim To describe a new surgical technique involving prefabrication of a bone flap for treatment of erectile dysfunction in a patient with sickle cell disease. Methods The descending branch of the lateral circumflex femoral artery was isolated and implanted within a cadaveric bone segment. The prefabricated flap was then transferred 2 months later as a neophallus for penile autoaugmentation. Results Bone scan showed viability of the bone flap after transfer. The patient was able to have vaginal intercourse and successfully achieve orgasm 2 months after the second stage surgery. Conclusions Prefabrication of a cadaveric bone flap and subsequent transfer is a novel and effective technique for treatment of erectile dysfunction refractory to medical management. This technique may be particularly useful for "implant cripples," who have no other surgical option. Salgado CJ, Chim H, Rowe D, and Bodner DR. Vascularized cadaveric fibula flap for treatment of erectile dysfunction following failure of penile implants.

Reconstruction of head and neck patients using free tissue transfer is perhaps the most challenging of areas in the human body. Although complications are inevitable in a percentage of patients, it is good postoperative care and monitoring that determines the success or failure of the reconstruction and also permits early salvage of a failing free flap. Teamwork and cooperation among members of the reconstructive team are critical. Here we review the significance of clinical care and monitoring of reconstructed head and neck patients in the intraoperative and postoperative periods. We also review different techniques and strategies for flap monitoring and anticoagulation used for free tissue transfers.

After studying this article, the participant should be able to: 1. Define the difference between vascular tumors and malformations. 2. Distinguish between the natural history of hemangiomas and that of vascular malformations. 3. Identify the different types of hemangiomas and vascular malformations and understand evaluation, treatment, and complications. 4. Understand the role of lymphaticovenular anastomoses in the treatment of extremity lymphedema.The International Society for the Study of Vascular Anomalies classification, which is the most widely accepted classification system in use, divides vascular anomalies into vascular tumors (inclusive of hemangiomas) and malformations. This serves as a guideline for diagnosis, evaluation, and treatment of these lesions.Although hemangiomas tend to have a predictable clinical course over the first year of life, going through proliferating, involuting, and involuted stages, vascular malformations demonstrate growth commensurate with age, often becoming more prominent in puberty. In addition, they never regress, and persist throughout life.Different modalities of treatment may be appropriate for vascular tumors and different subsets of vascular malformations. Details are provided in this review. Lymphaticovenular anastomoses provide an excellent addition to our methods of treatment of extremity lymphedema, and are made possible through development of supermicrosurgical techniques.Vascular anomalies have a high prevalence in the general population. Thus, it is vital that the plastic surgeon has a good understanding of classification, evaluation, and treatment options. Lymphedema is another common condition that is encountered. Understanding of lymphaticovenular anastomoses and their applications aids treatment planning for select patients.

A 5-year review of nosocomial infections, bacteraemia and wound colonization in patients admitted to a burn intensive care unit from June 2001 to May 2006 was carried out. All patients required intubation at some point, and ICU support. Data on bacterial and fungal isolates were entered prospectively into a hospital-wide computerized database. Nosocomial infections (NIs) were defined using standard CDC criteria. Seventy-six patients were admitted during the study period, with 57 qualifying for analysis. Forty-two patients (74%) developed 137 NIs, with 240 NIs/100 admissions. The most common NI was pneumonia (43%), followed by burn wound infection (34%), primary bloodstream infection (20%) and urinary tract infection (3%). The device specific rate of pneumonia was 143 infections per 1000 ventilator days. There were 113 episodes of bacteraemia and 173 episodes of wound colonization without infection. The most common organisms causing nosocomial infections were Acinetobacter sp. (n=33), followed by methicillin resistant Staphylococcus aureus (MRSA) (n=24) and Pseudomonas aeruginosa (n=22). A. baumannii isolates were highly multiresistant, with 82 distinct strains isolated from 47 patients (82% of patients). Data from this and other studies supports the hypothesis that A. baumannii is more common in tropical, warm climes necessitating vigorous infection control measures to optimise patient outcome.

We present a patient with an asymptomatic painless medial elbow swelling of one year's duration, which was diagnosed as a ganglion originating from a non-united avulsion fracture of the medial epicondyle with a pseudarthrosis. Medial elbow ganglia are unusual lesions typically arising from the medial aspect of the ulnohumeral joint capsule, often in combination with symptoms of cubital tunnel syndrome. To our knowledge, a ganglion arising from a pseudarthrosis has not been reported in the literature, and should be considered in the differential diagnoses of lesions encountered over the site of fracture non-union in proximity to a joint.

The finding of a persistent median artery coursing superficial to the flexor tendons in the distal forearm is described.

Background Fracture-dislocations of the proximal interphalangeal joint (PIPJ) remain a challenging problem to treat. Although there are a number of papers describing the use of dynamic external fixators and force couples for treatment of unstable PIPJ fracture-dislocations acutely, the literature is scarce on delayed treatment of PIPJ fracture-dislocations, where malunion of the articular surface may theoretically compromise postoperative range of motion (ROM) at the PIPJ. The purpose of this study was to evaluate the effectiveness of dynamic distraction external fixation (DDEF) for the delayed treatment of PIPJ fracture-dislocations at least 3 weeks after the inciting injury. Methods Ten consecutive patients were treated with delayed DDEF between 2010 and 2013. Postoperative ROM at the PIPJ was measured. Disabilities of the Arm, Shoulder and Hand (DASH) score and Michigan Hand Outcomes Questionnaire were administered to all patients postoperatively. Results Mean time from injury to surgery was 27.5 days. The mean follow-up period was 23.7 months (range 10–36). The mean active ROM at the PIPJ on final postoperative follow-up was 83.9° (range 52–100). None of the patients experienced pin-tract infections. Mean DASH score was 3.7 + 3.4 and mean Michigan Hand Outcomes Questionnaire score was 97.3 + 3.0. All patients returned to work and resumed normal activities. Conclusions Delayed treatment of unstable PIPJ fracture-dislocations with a DDEF is effective in restoring function to the PIPJ. Nascent malunion of the PIPJ articular surface does not compromise postoperative outcomes and the joint surface undergoes remodelling over time to restore a smooth and functional articular surface.

Within the carpus, the scaphoid is the most commonly fractured, and accounts for more than 60 % of all carpal bone fractures [5]. Nonunion is a problem that is encountered particularly often with scaphoid fractures, especially in those involving the proximal one third of the scaphoid. This relates to the blood supply of the scaphoid, which is primarily derived from branches from the radial artery entering the scaphoid through foramina on its distal dorsal ridge. The vascular supply of the proximal pole hence is derived in a retrograde fashion from these vessels proceeding from distal to proximal, and is easily disrupted following a fracture. With disruption of the blood supply of the proximal pole, AVN develops in approximately 3 % of all scaphoid fractures [1].

We present a patient with spontaneous compartment syndrome of the upper extremity in association with nephrotic syndrome and transient bacteremia, of which the exact cause of compartment syndrome was unclear. This is an extremely rare occurrence, and index of suspicion should be maintained even in the absence of trauma when a patient presents with acute swelling of the upper or lower extremity together with nephrotic syndrome.

Surgical procedures for the treatment of rheumatoid arthritis are aimed at restoring function and decreasing pain. Over the past four decades multiple procedures have been described in the management of early and late disease. This article will review the most common forms of surgery used in the treatment of rheumatoid arthritis.

BACKGROUND The aim of this study was to compare the incidence of neuroma formation and neuropathic pain following different techniques of nerve ablation in a rat sural nerve model. METHODS Rat sural nerve was subjected to four different techniques of ablation with standardized creation of a 1-cm gap (n = 15 in each group). These included nerve avulsion, transection and burying in muscle, transection and folding of nerve, and transection alone. Animals were killed after 3 months. Explanted nerves were sectioned and stained with Masson trichrome and S-100 stain against neural tissue. The maximal neural cross-sectional area and neural-to-connective tissue ratio was quantified. Quantitative reverse-transcriptase polymerase chain reaction (n = 5) was used to analyze relative mRNA expression of ciliary neurotrophic factor and calcitonin gene-related peptide. RESULTS Neural cross-sectional area was statistically increased (p < 0.05) compared with controls in folded, muscle buried, and transected specimens but decreased in avulsed specimens. The neural-to-connective tissue ratio was statistically decreased in the avulsed group. Relative mRNA expression of ciliary neurotrophic factor was lowest in muscle buried (4 percent of control) (p < 0.05) and avulsed specimens (15 percent of control) (p < 0.05) and higher in folded (52 percent of control) and transected specimens (75 percent of control). Relative mRNA expression of calcitonin gene-related peptide was highest in folded specimens (302 percent of control) (p < 0.05). CONCLUSIONS Folding and transection lead to increased histologic evidence of neuroma formation, whereas folding leads to neuropathic pain, assayed by calcitonin gene-related peptide expression. Avulsion and muscle burying are preferable techniques for nerve ablation and inhibit nerve regeneration, evidenced by decreased ciliary neurotrophic factor expression. Avulsion offers an alternative to muscle burying when there is no muscle in the vicinity to bury the transected nerve.