David L. Colen

Anatomical Basis and Clinical Application of Synovial Flaps in the Wrist and Distal Forearm.

Background: Neuropathic symptoms after median nerve repair at the wrist or secondary to refractory carpal tunnel syndrome may become debilitating. These symptoms develop because of perineural adhesions, intraneural fibrosis, and fixation of the nerve to the transverse carpal ligament after surgery, and often require neurolysis. Interposition of vascularized soft tissue over the median nerve at the time of neurolysis prevents recurrence of such adhesions. The synovial flap, fashioned from the synovial lining of the flexor tendon sheath, is an ideal tissue for this purpose. Previous authors have described the surgical technique of the synovial flap, but the anatomical basis and design of the flap have not been previously discussed. Methods: Twenty fresh cadaver upper extremities were injected with Microfil to analyze the arterial anatomy, flap dimensions, and arc of rotation of the flexor tendon synovium mobilized as a flap suitable for coverage of the median nerve at the wrist. The authors determined that both radial and ulnar-based flaps are clinically useful for providing coverage in the wrist and distal forearm. This flap was used in 18 patients with complicated median nerve lesions in this region. Results: All patients had an uncomplicated postoperative course. Of 13 patients treated for posttraumatic median nerve neuromas, all but two had significant resolution of symptoms. Conclusions: When used as a vascularized flap, the flexor tendon synovium provides adequate protection of the median nerve. Flap dimensions and vascularity of this tissue make it an ideal local flap option when performing reoperative surgery on the median nerve.

Burden of Hand Maladies in US Emergency Departments

Background: Hand conditions commonly present to the emergency department (ED), yet data are lacking regarding the magnitude of hand-related conditions in the emergency setting. The purpose of this study is to describe the burden and quantify the health care resource utilization of hand conditions seen in EDs across the United States. Methods: Using the National Emergency Department Sample, we identified all ED encounters by patients at least 18 years of age that were associated with a hand condition in 2009 to 2012. The primary outcomes were prevalence, etiology, and associated health care charges for specific categories of hand conditions. Results: The final sample included 34.4 million ED encounters associated with a common hand condition generating

Abstract P28. Soft Tissue Reconstruction after Complicated Knee Replacement: Principles and Predictors of Knee Salvage

180.4 billion in health care charges. The volume of hand-related presentations varied in a predictable and cyclical manner, peaking in July and waning in December of each year. Trauma was the most common etiology (77.5%) predominantly due to falls (26.2%) and lacerations (19.7%). Over 4 years, the volume of ED encounters rose (5% increase, P < .001) and as did the resulting health care charges (24.6% increase, P < .001). Conclusions: Our study confirms that hand-related conditions contribute significantly to ED volume and consume a growing quantity of health care resources in the United States. The volume of patients presenting to EDs with hand-related conditions fluctuates cyclically throughout the year. Open wounds are the most common cause of presentation and mostly occur in young adults, followed by joint pain, contusions, and fractures.

Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience.

PURPOSE: The most feared complication of total knee arthroplasty (TKA) is periprosthetic infection (1–5% of cases) which leads to prosthetic failure and may result in knee fusion or even limb loss. The optimal role of a plastic surgeon in salvaging a compromised TKA remains unclear. We sought to elucidate factors associated with TKA salvage and principles of reconstruction that optimize outcomes.

Abstract: Congenital Syndactyly Reconstruction of 391 Webspaces

Background Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem. Methods Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients. Results A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: “conservative management,” “excision of mesh with primary closure,” “single-stage reconstruction,” “immediate staged repair,” and “repair in contaminated field.” Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional (“secondary”) repairs after recurrence, 75% were eventually able to achieve “hernia-free” state. Conclusions This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.

Radial Longitudinal Deficiency: Recent Developments, Controversies, and an Evidence-Based Guide to Treatment

INtROdUCtION: Congenital syndactyly occurs in isolated and syndromic forms; method of reconstruction must be tailored to the type of syndactyly and postoperative function will depend on the preoperative state of the hand in addition to the method of reconstruction selected. We present the 18 year experience of surgical reconstruction of congenital syndactyly in all of its forms at a high throughput children’s hospital.