Scott D. Lifchez

Detailed neurovascular anatomy of the serratus anterior muscle: implications for a functional muscle flap with multiple independent force vectors.

A functional muscle free flap with multiple muscle segments that could be oriented independently to produce different force vectors would be beneficial in facial reanimation and upper extremity reconstruction. The serratus anterior muscle has this potential because two or more individual muscle slips can be transferred on a single vascular pedicle. Although serratus anterior muscular anatomy has been studied previously, little attention has been given to the intramuscular anatomy. Muscle slips 5 through 9 (and 10, if present) in 50 specimens from 27 cadavers were studied following intraarterial latex injection. Eight specimens were injected with a radiopaque material (latex/diatrizoate/lead mixture) for x-ray delineation of the intramuscular vascular pattern. Slips 5 through 9 are consistently supplied by a single dominant branch of the thoracodorsal artery and innervated by the long thoracic nerve. Dissection revealed that the long thoracic nerve and its branches invariably follow the artery and divide proximal to the corresponding arterial division. There is a consistent vascular pattern to each muscle slip, in which the serratus artery gives rise to common slip arteries, each of which supplies adjacent muscle slips. The mean length of a muscle slip from its origin on the rib periosteum to the division of the common slip artery is 9.6 cm. These findings imply that the slips may be separated to the level of these common slip arteries, with up to five slips transferred on a single neurovascular pedicle and each slip oriented independently to provide multiple muscle force vectors. With these possibilities, the reconstructive surgeon may be able to restore more natural facial animation and better intrinsic muscle function in the upper extremity.

Compression neuropathy of the radial nerve due to ganglion cysts.

Ganglions of the upper extremity are common. Radial nerve dysfunction, particularly radial sensory dysfunction, is a rare finding in association with a ganglion. We present our experience with two such ganglia and a review of the literature.

Long-term results of surgical treatment for hypothenar hammer syndrome.

Background: Ulnar artery occlusion at the wrist and proximal palm can cause debilitating pain and tissue loss. There is disagreement in the literature as to whether the diseased ulnar artery needs to be reconstructed or merely resected. The authors report the long-term outcomes of patients treated surgically with reconstruction of the ulnar artery. Methods: The long-term outcomes of 14 patients treated for this condition were evaluated. Comparisons of late postoperative to preoperative and early postoperative measurements were performed for digital brachial index. Subjective symptoms and function impairment were compared for preoperative and postoperative states using validated questionnaires. Comparisons were also made based on ulnar artery patency versus occlusion at late postoperative measurement. Results: Two patients underwent excision of the thrombosed segment and direct ulnar artery repair. All reconstructions were performed using vein grafts. Eight reconstructions remained patent at a mean 52 months postoperatively. All patients had a mean improvement in digital brachial index (0.82 versus 0.70), decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively. Patients with ulnar artery occlusion at final measurement had more improvement in digital brachial index (0.19 versus 0.03) and tended to have better subjective improvement in symptoms and function than those whose ulnar artery remained patent. Conclusions: Ulnar artery reconstruction in the setting of hypothenar hammer syndrome results in immediate and long-term improvement of commonly used objective and subjective measurements of digital blood flow. Interestingly, long-term follow-up demonstrates superior endpoints in those reconstructions that occluded. A proposed mechanism to explain this phenomenon is presented.

The Association of the H-Index and Academic Rank Among Full-Time Academic Hand Surgeons Affiliated With Fellowship Programs

PURPOSE To evaluate the association between the Hirsch index (a measure of publications and citations) and academic rank among hand surgeons. METHODS This was a cross-sectional study of full-time academic hand surgeons within Accreditation Council for Graduate Medical Education-approved hand surgery fellowship programs in the United States and Canada. The study variables were classified as bibliometric (h-index, I-10 index, total number of publications, total number of citations, maximum number of citations for a single work) and demographics (gender, training factors). The outcome was academic rank (instructor, assistant professor, associate professor, professor, endowed professor). Descriptive, bivariate, and multiple regression statistics were computed. RESULTS The sample was composed of 366 full-time academic hand surgeons; 86% were male and 98% had formal hand surgery fellowship training. The mean time since completion of surgical training was 17 ± 11 years. The distribution of primary faculty appointments was orthopedic surgery (70%) and plastic surgery (30%). Two hundred fifty surgeons (68%) were members of the American Society for Surgery of the Hand. The mean h-index was 10.2 ± 9.9 and was strongly correlated with academic rank. Gender was not associated with academic rank. Distribution of academic ranks was as follows: instructor (4%), assistant professor (28%), associate professor (40%), professor (22%), and endowed professor (5%). The h-index, years since completion of training, and American Society for Surgery of the Hand membership were associated with academic rank. The h-index had a high sensitivity and specificity for predicting academic rank. CONCLUSIONS The h-index is a reliable tool for quantitatively assessing research productivity and should be considered for use in academic hand surgery. CLINICAL RELEVANCE When evaluating candidates for academic promotion in hand surgery, the h-index is a potentially valuable tool for assessing research productivity and impact.

Guidelines for Ethical and Professional Use of Social Media in a Hand Surgery Practice

In growing numbers, patients are using social media platforms as resources to obtain health information and report their experiences in the health care setting. More physicians are making use of these platforms as a means to reach prospective and existing patients, to share information with each other, and to educate the public. In this ever-expanding online dialogue, questions have arisen regarding appropriate conduct of the physician during these interactions. The purpose of this article is to review the laws that govern online communication as they pertain to physician presence in this forum and to discuss appropriate ethical and professional behavior in this setting.

Comprehensive Observations of Resident Evolution: A Novel Method for Assessing Procedure-Based Residency Training

Background: Assessment of surgical skills in the operating room remains a challenge. Increasing documentation requirements of the Accreditation Council for Graduate Medical Education are necessitating mechanisms to document trainee competence without hindering operative turnover. The authors created a comprehensive electronic resource to facilitate plastic surgery training program compliance with changes mandated by Next Accreditation System Milestones and the ACGME. Methods: In 2013, the authors implemented the Comprehensive Observations of Resident Evolution, or CORE, a Web-based tool to assess plastic surgery residents. It comprises a rapid electronic assessment of resident operating room performance completed after each surgery; a data dashboard displaying graphical summaries of resident progress by case, Milestone, or current procedural terminology code; and an electronic Milestones tracker (MileMarker), which enables ongoing trainee assessments. Results: From January through October of 2014, 24 residents completed nearly 1300 Operative Entrustability Assessments. Thirty-eight percent of residents reported more immediate feedback regarding operative performance. The assessment demonstrates construct validity, which distinguishes novice residents from experienced residents. Individual case data identify resident-specific operative strengths and weaknesses. Using assessment data, the first two Clinical Competency Committee reviews were 81 percent and 87 percent shorter than Milestones pilot test site reports (average, 11.5 and 8 minutes versus 60 minutes per resident, respectively). Conclusions: Comprehensive Observations of Resident Evolution is capable of capturing operative performance data on all operating room cases by primary current procedural terminology code. It increases immediate attending/trainee feedback and assessment transparency, enables trainee self-monitoring, and informs end-of-rotation reviews, programwide assessments, and tailoring of training to address specific needs. It is a valuable resource for tracking resident progress in real-time while maintaining compliance with evolving ACGME requirements.

Integrating the NAS Milestones and Handheld Technology to Improve Residency Training and Assessment

OBJECTIVE To incorporate the use of an intuitive and robust assessment tool in conjunction with the Next Accreditation System Milestones to maximize opportunities for trainee performance feedback and continuous trainee assessment, with the long-term goal of increasing the rate of performance improvement and mastery of knowledge and surgical skills. DESIGN Pilot study. SETTING Johns Hopkins Medicine, Baltimore, MD. Primary, tertiary, and quaternary clinical care; institutional environment. PARTICIPANTS Experimental group: two randomly selected postgraduate year-1 integrated training program residents per year for 2 consecutive years from the Department of Plastic and Reconstructive Surgery. CONTROL GROUP traditionally trained residents from the integrated training program in the Department of Plastic and Reconstructive Surgery. Study duration: 7 years (until residents complete residency training). ANTICIPATED RESULTS This assessment strategy would create large amounts of informative data on trainees, which can be cross-referenced to determine trainee progress. Assessment data would be collected continuously from all faculty surgeons. Comparisons of faculty and resident self-assessments would facilitate resident evaluations. Ease of use of the data collection structure would improve faculty evaluation compliance and timely resident case report completion. CONCLUSIONS Improving the efficiency and efficacy of competency documentation is critical. Using portable technologies is an intuitive way to improve the trainee assessment process. We anticipate that this 2-pronged approach to trainee assessments would quickly provide large amounts of informative data to better assess trainee progress and inform Milestone assessments in a manner that facilitates immediate feedback. Assessments of faculty and resident satisfaction would help us further refine the assessment process as needed. If successful, this format could easily be implemented by other training programs. APPLICABLE PROJECT AREA Innovations in Surgical Education: Milestones.

Complex and Rare Fracture Patterns in Perilunate Dislocations

IntroductionThe wrist represents a complex anatomic region in the upper extremity and a highly functional and intricate structural joint. Perilunate injuries have classically been described as involving a greater or lesser arc as described by Mayfield and imply a specific pattern of force transmission. The greater and lesser arc classifications do not include descriptions of when non-scaphoid carpal fractures occur as part of a perilunate injury.Methods/ResultsWe present three cases of complex and rare perilunate fracture dislocation patterns and discuss the surgical management as a treatment model for these complex wrist injuries: the trans-scaphoid, trans-capitate perilunate dislocation, the trans-scapholunate ligament, trans-capitate dislocation, and the trans-scaphoid, trans-triquetral perilunate dislocation.DiscussionAlthough there is a low incidence of injury to non-scaphoid carpal bones, it is beneficial to understand the approach to the perilunate reduction and scaphoid fixation through a combined volar and dorsal approach, which will also allow for the reduction and fixation of more rare and complex carpal fractures.

Physician-Rating Web Sites: Ethical Implications

PURPOSE To understand the ethical and professional implications of physician behavior changes secondary to online physician-rating Web sites (PRWs). METHODS The American Society for Surgery of the Hand (ASSH) Ethics and Professionalism Committee surveyed the ASSH membership regarding PRWs. We sent a 14-item questionnaire to 2,664 active ASSH members who practice in both private and academic settings in the United States. RESULTS We received 312 responses, a 12% response incidence. More than 65% of the respondents had a slightly or highly unfavorable impression of these Web sites. Only 34% of respondents had ever updated or created a profile for PRWs, although 62% had observed inaccuracies in their profile. Almost 90% of respondents had not made any changes in their practice owing to comments or reviews. One-third of respondents had solicited favorable reviews from patients, and 3% of respondents have paid to improve their ratings. CONCLUSIONS PRWs are going to become more prevalent, and more research is needed to fully understand the implications. There are several ethical implications that PRWs pose to practicing physicians. We contend that it is morally unsound to pay for good reviews. The recourse for physicians when an inaccurate and potentially libelous review has been written is unclear. Some physicians have required patients to sign a waiver preventing them from posting negative comments online. We propose the development of a task force to assess the professional, ethical, and legal implications of PRWs, including working with companies to improve accuracy of information, oversight, and feedback opportunities. CLINICAL RELEVANCE It is expected that PRWs will play an increasing role in the future; it is unclear whether there will be a uniform reporting system, or whether these online ratings will influence referral patterns and/or quality improvement.

Upper Extremity Compartment Syndrome in the Setting of Deep Venous Thrombosis and Phlegmasia Cerulea Dolens: Case Report

Forearm compartment syndrome is an uncommon but emergent condition that can threaten limb and life. An uncommon cause of compartment syndrome is deep venous thrombosis, usually in the setting of phlegmasia cerulea dolens of the lower extremity. We present a case of compartment syndrome secondary to venous occlusion of the upper extremity due to phlegmasia cerulea dolens in a patient with metastatic lung cancer.