Aamir Siddiqui

Botulinum Toxin Type A: A Treatment Option for Digital Ischemia in Patients With Raynaud's Phenomenon

PURPOSE Raynauds phenomenon is an exaggerated vasospastic response that causes pallor and cyanosis. In the hand, it results in pain, disability, and the need for amputation. Current accepted medical and surgical treatments are not uniformly successful and have their inherent morbidities. Reports in the literature describe the use of botulinum toxin type A (BTX-A) for the treatment of vasospastic ischemia of the digits. We report the results of the treatment of recalcitrant digital ischemia with BTX-A in our institution. METHODS We performed a retrospective chart review between January 2003 and February 2007. All patients presented with a diagnosis of Raynauds phenomenon with worsening pain, discoloration, or nonhealing wound of the hand. Patients received BTX-A injections into the perineurovascular tissue of the wrist or the distal palm, or along the digit. Outcomes measured included pain rating, digit color and appearance, transcutaneous oxygen saturation, and healing of chronic ulcers. RESULTS Twenty-six patients were treated, with a total of 55 treatment encounters. Patients were observed for an average of 18 months. Statistically significant improvements were noted for pain score and digit transcutaneous oxygen saturation measurements after treatment (p < .05). We found smokers and women were more likely to have improved coloration and appearance after injections. Complications included localized injection-related pain and transient intrinsic muscle weakness. CONCLUSIONS Botulinum toxin type A significantly improves pain and improves healing in Raynauds patients with few complications. BTX-A was found to be a safe and useful treatment option for vasospastic digital ischemia.

A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis.

PURPOSE We designed a prospective, randomized study to evaluate the effects of iontophoresis delivery of dexamethasone versus corticosteroid injection therapy on patient outcomes. METHODS We randomized 82 patients to 10 mg dexamethasone via iontophoresis using a self-contained patch with a 24-hour battery; 10 mg dexamethasone injection; or 10 mg triamcinolone injection. All patients received the same hand therapy protocol. Primary outcomes tracked were change in grip strength (flexion vs extension), pain, and function scores on a validated questionnaire. The secondary outcome was return-to-work status. Patients were evaluated at baseline, completion of physical therapy, and 6-month follow-up. RESULTS The iontophoresis patients had statistically significant improvement in grip strength at the conclusion of hand therapy compared with baseline. They were also more likely to get back to work without restriction. By 6-month follow-up, all groups had equivalent results for all measured outcomes. CONCLUSIONS Dexamethasone via iontophoresis produced short-term benefits because for this group grip strength and unrestricted return to work were significantly better. This study suggests that this iontophoresis technique for delivery of corticosteroid may be considered a treatment option for patients with lateral epicondylitis. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.

Recurrence of Giant Cell Tumors in the Hand: A Prospective Study

PURPOSE Giant cell tumors of the hand remain a treatment dilemma: treatment requires a balance between extensive dissections for excision versus risk of recurrence. There is no consensus regarding how best to manage this balance. The purpose of this study was to identify the recurrence rate of giant cell tumors of the hand, as well as the correlation with the specific tissue type involved. METHODS Two hundred thirteen cases of giant cell tumor of the hand were recorded in a prospectively designed, anatomically based registry that identified tumor location and surgical planes entered and tissues excised during the procedure. Mean follow-up was 51 months. Demographic and follow-up data were also tracked. The primary outcome tracked was tumor recurrence. Statistical analysis was conducted using chi-square analysis and the Fisher exact test to determine which perioperative and intraoperative factors were associated with tumor recurrence. RESULTS There were 27 recurrences among our cases. Tumors involving the extensor tendon, flexor tendon, or joint capsule had the strongest correlation with recurrence: 12, 8, and 12 cases, respectively. Conversely, there was only one recurrence among the patients who did not have any involvement of either the flexor or extensor tendons or joint capsules. There was no association for involvement of skin, neurovascular bundle, tendon sheath, or bone at the initial excision. No identifiable preoperative or postoperative factors were linked to recurrence. CONCLUSIONS Our study shows that direct involvement of the extensor tendons, flexor tendons, or joint capsule puts patients in a high-risk category with respect to recurrence. Based on these findings, efforts regarding close monitoring and the role of adjuvant therapy should be directed at the high-risk population. This information may be helpful for hand surgeons developing evidence-based treatment algorithms for giant cell tumor in the hand. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.

Human acellular dermal matrix (AlloDerm®) dimensional changes and stretching in tissue expander/implant breast reconstruction.

BACKGROUND Human acellular dermal matrix (HADM) is widely used for post-mastectomy tissue expander/implant breast reconstruction. Since HADM has been shown to stretch following placement in other surgical settings, we hypothesised that stretching would occur in breast reconstruction as well. The goal of the study was to quantify the in situ stretch properties of HADM over time in patients undergoing this procedure. METHODS This was an open-label, prospective case series in adult women who underwent post-mastectomy tissue expander/implant breast reconstruction using HADM. HADM construct size was determined at postoperative day 1 and month 3 via ultrasound tracking of metallic 3-mm vessel clips embedded in the graft. Dimensional changes were further examined in four equally sized segments (medial, lateral and two central) of the matrix. Patient satisfaction was evaluated at month 3 (a modified version of the Breast Q™ patient questionnaire) and compared with satisfaction reported by a non-HADM reconstruction cohort. RESULTS A total of 31 patients underwent breast reconstruction with HADM. Mean (standard deviation) perimeter increased from 38 (6) cm on postoperative day 1-42 (7) cm at month 3 (+11%; P=0.002). Surface area increased from 73 (22) to 88 (28) cm2 (+21%; range, 4-35%; P=0.002). The greatest expansion occurred in the HADM medial and lateral segments (range, 18-30% across the four segments). Patient satisfaction was comparable with that of non-HADM patients. Complications in the HADM group included late seroma, red breast syndrome and urinary tract infection. Complications in the non-HADM cohort included cellulitis, expander explantation, delayed wound healing and skin necrosis. CONCLUSIONS During short-term follow-up, HADM exhibited a modest degree of stretching during tissue expander/implant breast reconstruction and was associated with few complications and a high level of patient satisfaction.

Recurring pressure ulcers: Identifying the definitions. A National Pressure Ulcer Advisory Panel white paper

Currently, there is a lack of consensus regarding the accepted terminology pertaining to the pressure ulcer healing progression and recidivism. This lack of uniformity can negatively impact initiation of treatment pathways, completion of appropriate interventions, clinical documentation, medical coding, patient education, discharge planning and healthcare revenue through out the healthcare system. The purpose of this paper is to introduce a standard nomenclature as it pertains to pressure ulcer healing progression and any recidivism that may occur. The National Pressure Ulcer Advisory Panel has formulated a framework of terms regarding pressure ulcer progression. We also developed a clearer nomenclature for lack of progress and recidivism of pressure ulcers. This document should serve as a starting point for the discussion of the pressure ulcer care, research, and terminology.

Pyoderma Gangrenosum Following the Revision of a Breast Reconstruction and Abdominoplasty

Pyoderma gangrenosum (PG) is a rare ulcerative dermatologic disease and little is known about its etiology and pathogenesis. Recent reports show that there have been limited but increasing number of cases of PG following aesthetic surgeries. Post-surgical PG is often misdiagnosed, which can have serious clinical consequences. The following case report describes a young woman who underwent a cosmetic breast augmentation and abdominoplasty which was complicated by post-operative necrotizing fasciitis. She was presented one year later for surgical correction of her acquired breast and abdominal deformities. Post-operatively she developed a severe inflammatory skin response presumed to be a wound infection. However, after repeated surgical debridements, the wounds persisted without a defined bacterial or fungal organism. After clinical exclusion of all other etiologies, PG was diagnosed and confirmed with histopathology. The patient was subsequently treated with aggressive immunosuppressive therapy, and the lesions resolved without any signs of residual PG. This case report attempts to increase awareness for the rare post-surgical complication of PG in aesthetic surgery and to improve future diagnosis and management of such cases.

Posterior Iliac Crest Bone Graft: How Much Is Enough?

Abstract Autogenous bone grafting is the gold standard for reconstructing craniofacial defects. Mandibular defects are reliably reconstructed with free nonvascularized bone, such as from the posterior iliac crest (PIC). In light of improved imaging, including 3-dimensional computed tomography scanning, a more accurate defect estimation is possible. A strong understanding of bone graft available is necessary. The purpose of this study was an updated review of the dissection and quantification of the amount of bone that can be safely harvested. Bilateral bicortical osteotomy was performed on 55 cadavers to obtain 110 PIC bone grafts. Demographic factors and bicortical osteotomy measurements were recorded. Average osteotomy lengths, widths, and depths were 7.4, 5.5, and 1 cm, respectively. The average bicortical osteotomy volume was 40.6 cm3. During the dissection, the authors identified 2 anatomical variants with respect to muscle insertion into the PIC. In variation 1, which occurred in 62% of dissections, the latissimus dorsi and thoracolumbar fascia did not originate from the PIC. When this occurred, the quadratus lumborum attached to the PIC. In variation 2, which occurred in 38% of dissections, the latissimus dorsi and thoracolumbar fascia originate from the PIC. By identifying the maximal bone volume obtainable from a PIC graft and noting 2 anatomical variants, this study allows for more accurate surgical planning and management.

54: COST SAVINGS FROM REAL TIME PRESSURE MAPPING ON HOSPITAL ACQUIRED PRESSURE ULCERS IN A MEDICAL ICU

Learning Objectives: Annually

Benefits of Early Active Mobility in the Medical Intensive Care Unit: A Pilot Study

9.6-

Self-turning for pressure injury prevention

11.6 billion is spent on management of pressure ulcers. Our institution has combined policy and the use of continuous real time pressure mapping (RTPM) to combat Hospital acquired pressure ulcers (HAPU). RTPM technology allows the bedside care team to identify areas of increased pressure and provide effective patient repositioning. We hypothesize that using RTPM will translate into a significant cost savings. Methods: A 3-month prospective controlled study was conducted in a Medical intensive care unit (MICU) of a 900-bed teaching hospital. All MICU admissions were assigned to 2 different groups. Group A assigned to a bed equipped with a RTPM device and Group B assigned to a bed without. The patients’ skin was assessed daily and weekly to recognize and treat HAPUs. Control group patients were turned every 2 hours per MICU policy. RTPM patients were also turned every 2 hours, however turned in a way to offload high-pressure points that corresponded to the RTPM graphical display. Outcomes measured included development of ulcers between groups and cost savings. Cost savings was calculated using a methodology similar to a prior ICU financial modeling of cost savings after implementation of an ICU early physical rehabilitation program. Results: Two patients in Group A (n=217) developed HAPUs (0.9%) compared to ten patients in Group B (n=213; 4.7%; P=0.02). RTPM vs Control group comparison showed no differences in age, length of stay, acuity, patient weight, co-morbidities and Braden score. Incurred cost of development of HAPUs in the RTPM vs control group was