Publications by authors named "Kyle R Eberlin"

150 Publications

Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation.

Hand (N Y) 2022 Jul 19:15589447221109635. Epub 2022 Jul 19.

Massachusetts General Hospital, Boston, USA.

Background: Demographic information related to phalangeal fractures that undergo simultaneous vascular repair, as well as their complication and reoperation profiles, remain incompletely understood. This study aimed to examine the patient and fracture characteristics influencing the outcomes after these injuries in a large Unites States adult patient cohort and to identify risk factors associated with unplanned reoperation of these fractures.

Methods: A retrospective study was performed, identifying 54 phalangeal fractures in 48 patients; all fractures were also associated with vascular injuries requiring repair. Patients with digital amputations were excluded. A manual chart review was performed to collect epidemiologic, radiographic, and surgical outcome information.

Results: The incidence of phalangeal fractures undergoing vascular repair was higher in the non-dominant hand, middle finger, proximal phalanx, and phalangeal shaft. Most (52.9%) fractures were due to occupational injury, with the most common mechanism being sharp injuries. More than half of the fractures had a nerve injury, and 13% required a vein graft for vascular repair. More than half of the fractures required at least one reoperation, most commonly due to "stiffness/tendon adhesion" (50%) and "nonunion or delayed union" (21.4%). In multivariable analysis, thumb (odds ratio [OR]: 35.1, = .043) and index (OR: 14.0, = .048) fingers' fractures were found to be independently associated with unplanned reoperation.

Conclusions: Phalangeal fractures requiring vascular repair occurred most often in the occupational setting and more than 50% required at least one unplanned reoperation. Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up.
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http://dx.doi.org/10.1177/15589447221109635DOI Listing
July 2022

Reply: Assessment of Plastic Surgery Residency Applications without United States Medical Licensing Examination Step 1 Scores.

Plast Reconstr Surg 2022 Jul 12. Epub 2022 Jul 12.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA.

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http://dx.doi.org/10.1097/PRS.0000000000009376DOI Listing
July 2022

Factors Related to Neuropathic Pain following Lower Extremity Amputation.

Plast Reconstr Surg 2022 08 27;150(2):446-455. Epub 2022 Jul 27.

From the Department of Orthopaedic Surgery, Hand and Upper Extremity, Foot and Ankle, and Orthopaedic Oncology Services, the Harvard Medical School Orthopedic Trauma Initiative, and the Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School.

Background: Lower extremity amputations are common, and postoperative neuropathic pain (phantom limb pain or symptomatic neuroma) is frequently reported. The use of active treatment of the nerve end has been shown to reduce pain but requires additional resources and should therefore be performed primarily in high-risk patients. The aim of this study was to identify the factors associated with the development of neuropathic pain following above-the-knee amputation, knee disarticulation, or below-the-knee amputation.

Methods: Retrospectively, 1565 patients with an average follow-up of 4.3 years who underwent a primary above-the-knee amputation, knee disarticulation, or below-the-knee amputation were identified. Amputation levels for above-the-knee amputations and knee disarticulations were combined as proximal amputation level, with below-the-knee amputations being performed in 61 percent of patients. The primary outcome was neuropathic pain (i.e., phantom limb pain or symptomatic neuroma) based on medical chart review. Multivariable logistic regression was performed to identify independent factors associated with neuropathic pain.

Results: Postoperative neuropathic pain was present in 584 patients (37 percent), with phantom limb pain occurring in 34 percent of patients and symptomatic neuromas occurring in 3.8 percent of patients. Proximal amputation level, normal creatinine levels, and a history of psychiatric disease were associated with neuropathic pain. Diabetes, hypothyroidism, and older age were associated with lower odds of developing neuropathic pain.

Conclusions: Neuropathic pain following lower extremity amputation is common. Factors influencing nerve regeneration, either increasing (proximal amputations and younger age) or decreasing (diabetes, hypothyroidism, and chronic kidney disease) it, play a role in the development of postamputation neuropathic pain.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000009334DOI Listing
August 2022

Telemedicine and Plastic Surgery: Principles from the American Society of Plastic Surgeons Health Policy Committee.

Plast Reconstr Surg 2022 07 20;150(1):221e-226e. Epub 2022 May 20.

From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School; Avera Medical Group Plastic and Reconstructive Surgery; National Accounts; Hadeed Center for Plastic and Reconstructive Surgery; Ver Halen Aesthetics and Plastic Surgery; Department of Plastic Surgery, Vanderbilt University Medical Center; American Society of Plastic Surgeons; and Division of Plastic Surgery, Albany Medical Center.

Summary: In the wake of the recent coronavirus disease of 2019 public health emergency, care delivery by means of telemedicine using audiovisual virtual platforms has become an important tool for patient communication. There are many logistic, medicolegal, and practical aspects of telemedicine that should be considered by the practicing plastic surgeon. Successful virtual patient interactions require an understanding of medical licensure requirements to perform telemedicine visits in a certain region. In addition, it is imperative to be familiar with specific liability and malpractice concerns, in addition to Health Insurance Portability and Accountability Act regulations before conducting electronic visits. During consultations, providers should be aware of proper physician conduct and the potential role of chaperones. Furthermore, appropriate visit documentation, in addition to telemedicine billing and coding, has to be ensured. Lastly, plastic surgeons should adhere to the rules of controlled substance prescription by means of telemedicine platforms. This article describes these salient topics surrounding telemedicine visits that are faced by plastic surgeons and discusses strategies to optimize and ensure safe use of virtual platforms.
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http://dx.doi.org/10.1097/PRS.0000000000009238DOI Listing
July 2022

Prolonged Opioid Use following Hand Surgery: A Systematic Review and Proposed Criteria.

Plast Reconstr Surg Glob Open 2022 Apr 8;10(4):e4235. Epub 2022 Apr 8.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Mass.

Prolonged opioid use after surgery has been a contributing factor to the ongoing opioid epidemic. The purpose of this systematic review is to analyze the definitions of prolonged opioid use in prior literature and propose appropriate criteria to define postoperative prolonged opioid use in hand surgery.

Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 130 studies were included for review. The primary outcome was the timepoint used to define prolonged opioid use following surgery. The proportion of patients with prolonged use and risk factors for prolonged use were also collected for each study. Included studies were categorized based on their surgical specialty.

Results: The most common timepoint used to define prolonged opioid use was 3 months (n = 86, 67.2% of eligible definitions), ranging from 1 to 24 months. Although 11 of 12 specialties had a mean timepoint between 2.5 and 4.17 months, Spine surgery was the only outlier with a mean of 6.90 months. No correlation was found between the definition's timepoint and the rates of prolonged opioid use.

Conclusions: Although a vast majority of the literature reports similar timepoints to define prolonged postoperative opioid use, these studies often do not account for the type of procedures being performed. We propose that the definitions of postoperative prolonged opioid use should be tailored to the level and duration of pain for specific procedures. We present criteria to define prolonged opioid use in hand surgery.
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http://dx.doi.org/10.1097/GOX.0000000000004235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8994078PMC
April 2022

Reoperation After Operative Treatment of Open Finger Fractures.

Hand (N Y) 2022 Apr 7:15589447211043191. Epub 2022 Apr 7.

Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital - Harvard Medical School, Boston, MA, USA.

Background: Our primary aim was to develop a prediction model for return to the operating room (OR) after open finger fractures by studying the reoperation rate of open finger fractures based on patient demographics, injury mechanism, injury severity, and type of initial surgical fixation. The secondary aim was to study the predictors for secondary surgery due to nonunion, postoperative infection, and secondary amputation.

Methods: In the retrospective chart review, 1321 open finger fractures of 907 patients were included. Demographic-, injury-, and treatment-related factors were gathered from medical records.

Results: We found that open fractures involving the thumb had lower odds of undergoing secondary surgery. Crush injury, proximal phalangeal fracture, arterial injury, other injured fingers, and other injuries to the ipsilateral hand were associated with higher odds of undergoing secondary surgery. However, the associated factors we identified were not powerful enough to create a predictive model. Other injury to the ipsilateral hand, vein repair, and external fixator as initial treatment were associated with postoperative nonunion. Crush injury and proximal phalangeal fracture were associated with postoperative infection. No factors were associated with secondary amputation.

Conclusions: A quarter of open finger fractures will likely need more than one surgical procedure, especially in more severely injured fingers, due to crush or with vascular impairment. Furthermore, fractures involving the thumb have less reoperation, while fractures involving the proximal phalanx have poorest outcomes.
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http://dx.doi.org/10.1177/15589447211043191DOI Listing
April 2022

RPNI, TMR, and Reset Neurectomy/Relocation Nerve Grafting after Nerve Transection in Headache Surgery.

Plast Reconstr Surg Glob Open 2022 Mar 25;10(3):e4201. Epub 2022 Mar 25.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

In the context of headache surgery, greater occipital nerve (GON) transection is performed when the nerve appears severely damaged, if symptoms are recurrent or persistent, and when neuromas are excised. Lesser occipital nerve (LON) excision is commonly performed during the primary decompression surgery. Advanced techniques to address the proximal nerve stump after nerve transection such as regenerative peripheral nerve interface (RPNI), targeted muscle reinnervation (TMR), relocation nerve grafting, and reset neurectomy have been shown to improve chronic pain and neuroma formation. These techniques have not been described in the head and neck region.

Methods: This article describes RPNI, TMR, and reset neurectomy with GON autograft relocation to prevent chronic pain and neuroma formation after GON/LON transection.

Results: RPNI and TMR are feasible options in patients undergoing GON/LON transection. Further, relocation nerve grafting with GON autograft relocation is a method that is beneficial in patients with diffuse nerve injury requiring proximal nerve division.

Conclusion: Advanced nerve reconstruction techniques should be considered in headache surgery following GON/LON transection.
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http://dx.doi.org/10.1097/GOX.0000000000004201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8955094PMC
March 2022

Reoperation Following Zone II Flexor Tendon Repair.

Hand (N Y) 2022 Feb 26:15589447211043220. Epub 2022 Feb 26.

Massachusetts General Hospital, Boston, USA.

Background: The goal of zone II flexor tendon surgery is to perform a repair with sufficient strength to withstand the forces encountered during rehabilitation. Postoperative rerupture and adhesion formation may lead to reoperation. This study aimed to determine the factors associated with reoperation after primary zone II flexor tendon repair.

Methods: In this retrospective case series, a total of 252 fingers in 201 patients underwent zone II flexor tendon repair. A medical record review was performed to collect data regarding patient demographics, injury and treatment characteristics and postoperative complications including reoperation. Reoperation was defined as any unplanned surgical procedure performed after initial flexor tendon repair.

Results: There were 49 fingers (19%) in 42 patients that underwent reoperation at a median of 5.5 (interquartile range: 2.8-7.9) months. Older age, workers' compensation, and a Kessler-type repair of the flexor digitorum profundus were independently associated with reoperation.

Conclusions: In vitro studies suggest that Kessler-type repairs are inferior compared with other suture configurations. Our study demonstrates a clinical correlation to these biomechanical studies. Our results suggest that Kessler-type repairs are inferior compared with non-Kessler-type repairs, due to postoperative complications requiring secondary surgeries.
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http://dx.doi.org/10.1177/15589447211043220DOI Listing
February 2022

Are We Working Harder for Less Pay? A Survey of Medicare Reimbursement for Hand and Upper Extremity Surgery.

Plast Reconstr Surg 2022 Apr;149(4):711e-719e

From the Johns Hopkins Hospital; and Massachusetts General Hospital.

Background: Ongoing concern for declining Medicare payment to surgeons may incentivize surgeons to perform more cases to maintain productivity goals. The authors evaluated trends in physician payment, patient charges, and reimbursement ratios for the most common hand and upper extremity surgical procedures.

Methods: The authors examined Medicare surgeon payment, patient charges, and surgical volume from 2012 to 2017 for 83 common surgical procedures, incorporating the year-to-year Consumer Price Index to adjust for inflation. The reimbursement ratio was calculated by dividing payment by charge. Weighted (by surgery type and volume) averages were calculated.

Results: Total Medicare surgeon payment increased 5.6 percent to $272 million for the studied procedures. Patient charges were seven times greater than payment, growing 24 percent to $1.9 billion. Despite growth of total payment, the average overall weighted payment for a single surgery decreased 3.5 percent. The average weighted patient charge increased 8 percent, whereas the reimbursement ratio decreased 13 percent. A hand surgeon would need to perform three more cases per 100 in 2017 to maintain the same reimbursement received in 2012. After categorizing these 83 surgical procedures, distal radius fixation (>3 parts, 21 percent increase; >2-part intra-articular, extra-articular, and percutaneous pinning, 17 percent increase), bony trauma proximal to the distal radius (10 percent increase), and upper extremity flap (5 percent increase) were subject to the greatest increases in payment. Payment for forearm fasciotomy (39 percent decrease), endoscopic carpal tunnel release (30 percent decrease), and mass excisions proximal to the wrist (18 percent decrease) decreased the most.

Conclusions: From 2012 to 2017, despite a disproportionate increase in procedure charges, Medicare surgeon payment has not decreased substantially; however, total reimbursement is multifactorial and involves multiple sources of revenue and cost.
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http://dx.doi.org/10.1097/PRS.0000000000008906DOI Listing
April 2022

Long-Term Opioid Use Following Surgery for Symptomatic Neuroma.

J Reconstr Microsurg 2022 Feb 16;38(2):137-143. Epub 2021 Jul 16.

Division of Plastic Surgery, Hand Surgery, and Peripheral Nerve Surgery, Massachusetts General Hospital, Harvard Medical School, Boston.

Background:  Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery.

Methods:  After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5-16.8 years) following surgery. Neuroma excision followed by nerve implantation ( = 39, 51%), nerve reconstruction/repair ( = 18, 23%), and excision alone ( = 16, 21%) were the most common surgical treatments.

Results:  Overall, 27% ( = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36-14.3,  = 0.013).

Conclusion:  Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.
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http://dx.doi.org/10.1055/s-0041-1731640DOI Listing
February 2022

Initial Treatment Choice Affects Cost-Effectiveness and Reintervention Rates for Dupuytren Contracture: A National Census Among Veterans Affairs Patients.

Hand (N Y) 2022 Jan 29:15589447211072251. Epub 2022 Jan 29.

Massachusetts General Hospital, Harvard Medical School, Boston, USA.

Background: A multitude of treatments for Dupuytren contracture are available, including both invasive and minimally invasive options. This study compares the reintervention rates and costs associated with various treatment options for Dupuytren disease (DD) within the Veterans Affairs (VA) Health Administration.

Methods: Using the Corporate Data Warehouse, a national census was performed including all patients treated for DD in years 2014 to 2020 within the VA health care system. Patients treated with collagenase clostridium histolyticum (CCH), percutaneous needle aponeurotomy (PNA), open fasciotomy, palmar fasciectomy, single finger fasciectomy, and multifinger fasciectomy were compared. The total cost of initial treatment was compared between modalities. The 5-year reintervention rates were compared using a Kaplan-Meier analysis.

Results: During the study period, 8530 patients were treated for DD (3501 fasciectomy, 3351 CCH, 880 PNA, 798 fasciotomy). The overall median treatment cost was found to be the least for PNA ( < .0001). The 5-year reintervention rates were significantly lower for single finger fasciectomy (6.5%), operative fasciotomy (8.2%), and palmar fasciectomy (9%) when compared with PNA (12.3%), multifinger fasciectomy (13.1%), and CCH (14.4%) ( < .001). However, reintervention rates were comparable between patients treated with PNA, multifinger fasciectomy, and CCH ( > .05).

Conclusions: Within the VA population, PNA is the most affordable procedure per treatment episode and is associated with reintervention rates that are comparable to those of CCH. Multifinger fasciectomy, CCH, and PNA had comparable reintervention rates. The differences in reintervention rates may partially be explained by patients' willingness to consider additional treatment to correct any remaining or recurrent deformity.
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http://dx.doi.org/10.1177/15589447211072251DOI Listing
January 2022

Predicting Academic Performance during Plastic Surgery Residency: Can Step 2 Scores Reliably Replace Step 1?

J Surg Educ 2022 May-Jun;79(3):828-836. Epub 2021 Dec 21.

Division of Plastic, Oral and Maxillofacial Surgery, Duke University, Durham, North Carolina. Electronic address:

Objective: Step 1 will transition to a pass/fail system in 2022. This study aimed to characterize the effects of this change on integrated plastic surgery program directors' selection criteria and assess whether Step 2 Clinical Knowledge (CK) can replace Step 1 as an application selection metric.

Design: Online survey that was administered to a collaborative group of ten plastic surgery program directors collecting USMLE Step 1, Step 2 CK, In-Service, and written board scores for 3 years of graduated integrated residents.

Setting: Ten academic integrated plastic surgery programs.

Participants: Data from 80 graduated integrated plastic surgery residents.

Results: Across 80 included integrated residents, mean (SD) Step 1 score was 247 (13), Step 2 CK was 249 (13), PGY1-6 In-Service percentiles varied from 45 to 53 percentile, and written board pass rate was 98.3%. Both Step 1 and Step 2 CK correlated highly with In-Service percentiles (both p < 0.001), with Step 2 CK scores correlating similarly with In-Service performance compared to Step 1 (rho 0.359 vs. 0.355, respectively). Across applicant characteristics, program directors reported the highest relative increase in Step 2 CK importance after Step 1 transitions to pass/fail.

Conclusions: Step 2 CK correlates similarly with plastic surgery In-Service performance compared to Step 1. While Step scores do not necessarily correlate with residency performance, Step 2 CK may also be used as an application screening metric for programs seeking objective data to differentiate plastic surgery applicants.
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http://dx.doi.org/10.1016/j.jsurg.2021.11.015DOI Listing
May 2022

Reply: Preparation for Hand Surgery Fellowship: A Comparison of Resident Training Pathways.

Plast Reconstr Surg 2022 01;149(1):144e-145e

Division of Plastic Surgery, Massachusetts General Hospital, Boston, Mass.

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http://dx.doi.org/10.1097/PRS.0000000000008616DOI Listing
January 2022

Targeted Muscle Reinnervation in Partial Hand Amputations.

Plast Reconstr Surg Glob Open 2021 May 28;9(5):e3542. Epub 2021 May 28.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Mass.

Targeted muscle reinnervation (TMR) surgery has been shown to aid in prevention and treatment of neuropathic pain. Technical and anatomical descriptions of TMR surgery for upper extremity amputees (including transradial, transhumeral, and forequarter amputations) have been reported, yet such descriptions of TMR surgery for partial hand amputations are currently lacking. Herein we outline the technique of different types of partial hand amputation TMR surgeries to serve as a reference and guide. A retrospective review was performed by our multi-institutional team to identify clinical cases where partial hand TMR surgeries were performed. Patient demographics, characteristics, amputation subtype, nerve transfer, pain score, pain outcome, and functional outcome data were collected and analyzed. From January 2018 to September 2019, 13 patients underwent partial hand TMR procedures. Eight cases resulted from trauma, and 6 were secondary to oncologic procedures. The amputations consisted of 8 ray, 2 trans-metacarpal, 2 radial-sided hand, and 1 index finger amputation with recurrent painful neuromas. Twelve patients were weaned off narcotics completely and only 3 remained on a neuromodulator for ongoing pain control. Technical considerations for partial hand TMR surgery have been outlined, with early pilot data showing beneficial pain control outcomes.
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http://dx.doi.org/10.1097/GOX.0000000000003542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8647892PMC
May 2021

Soft-tissue coverage for wound complications following total elbow arthroplasty.

Clin Shoulder Elb 2021 Dec 1;24(4):245-252. Epub 2021 Dec 1.

Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Background: In patients with total elbow arthroplasty (TEA), the soft-tissue around the elbow can be vulnerable to soft-tissue complications. This study aims to assess the outcomes after soft-tissue reconstruction following TEA.

Methods: We retrospectively included nine adult patients who underwent soft-tissue reconstruction following TEA. Demographic data and disease characteristics were collected through medical chart reviews. Additionally, we contacted all four patients that were alive at the time of the study by phone to assess any current elbow complications. Local tissue rearrangement was used for soft-tissue reconstruction in six patients, and a pedicle flap was used in three patients. The median follow-up period was 1.3 years (range, 6 months-14.7 years).

Results: Seven patients (78%) underwent reoperation. Four patients (44%) had a reoperation for soft-tissue complications, including dehiscence or nonhealing of infected wounds. Five patients (56%) had a reoperation for implant-related complications, including three infections and two peri-prosthetic fractures. At the final follow-ups, six patients (67%) achieved successful wound healing and two patients had continued wound healing issues, while two patients had an antibiotic spacer in situ and one patient underwent an above-the-elbow amputation.

Conclusions: This study reports a complication rate of 78% for soft-tissue reconstructions after TEA. Successful soft-tissue healing was achieved in 67% of patients, but at the cost of multiple surgeries. Early definitive soft-tissue reconstruction could prove to be preferable to minor interventions such as irrigation, debridement, and local tissue advancement, or smaller soft-tissue reconstructions using local tissue rearrangement or a pedicled flap at a later stage.
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http://dx.doi.org/10.5397/cise.2021.00409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8651597PMC
December 2021

A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache.

Plast Reconstr Surg 2021 Dec;148(6):1308-1315

From the Division of Plastic and Reconstructive Surgery and the Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School.

Background: Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies.

Methods: One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data.

Results: The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups.

Conclusions: The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.
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http://dx.doi.org/10.1097/PRS.0000000000008574DOI Listing
December 2021

The Octopus Procedure Combined with Targeted Muscle Reinnervation for Elective Transhumeral Amputation.

Plast Reconstr Surg Glob Open 2021 Nov 16;9(11):e3931. Epub 2021 Nov 16.

Massachusetts General Hospital, Boston, Mass.

Optimizing prosthetic function and tolerance are key principles of performing an elective upper extremity amputation. It is common for upper extremity amputees to experience issues related to nonoptimal prosthetic control and pain. Targeted muscle reinnervation and regenerative peripheral nerve interfaces in elective transhumeral amputations have been introduced as techniques to address the paucity of signals that may exist for myoelectric control postamputation. These techniques require the denervation of muscle and rely on delayed muscle reinnervation to provide eventual signal amplification for prosthetic function. In addition, the fascicles cannot be separated enough to provide signals to each individual muscle. Use of native innervated forearm musculature can provide more immediate and specific signals for prosthetic use. These native muscles are often not available for use due to trauma, denervation, or dysvascularization. In elective amputations, they can be used as spare parts to provide more signals for the sensors on a myoelectric prosthetic. The concept has been used in partial hand amputations and allowed for individual digital control at the terminal prosthetic device. In this study, we describe a novel technique used for an elective transhumeral amputation utilizing native innervated, vascularized musculature to provide intuitive control of a myoelectric prosthetic.
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http://dx.doi.org/10.1097/GOX.0000000000003931DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8594661PMC
November 2021

Reply: The Impact of Social Media on Plastic Surgery Residency Applicants.

Ann Plast Surg 2021 Oct 7. Epub 2021 Oct 7.

Division of Plastic and Reconstructive Surgery Massachusetts General Hospital Boston, MA

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http://dx.doi.org/10.1097/SAP.0000000000002996DOI Listing
October 2021

Standardizing Plastic Surgery Away Rotations: A Call for Greater Equity and Transparency.

Plast Reconstr Surg 2021 Nov;148(5):874e-875e

Department of Plastic Surgery, Department of Biomedical Informatics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tenn.

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http://dx.doi.org/10.1097/PRS.0000000000008438DOI Listing
November 2021

Reply: Revision Carpal Tunnel Release: Risk Factors and Rate of Secondary Surgery.

Plast Reconstr Surg 2021 08;148(2):309e-310e

Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

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http://dx.doi.org/10.1097/PRS.0000000000008123DOI Listing
August 2021

The Use of Peripheral Nerve Stimulation in Conjunction with TMR for Neuropathic Pain.

Plast Reconstr Surg Glob Open 2021 Jun 22;9(6):e3655. Epub 2021 Jun 22.

Massachusetts General Hospital, Boston, Mass.

Targeted muscle reinnervation and regenerative peripheral nerve interfaces are increasingly utilized strategies to mitigate phantom and residual limb pain in amputees. These interventions are successful, yet often imperfect in completely ameliorating neuropathic pain following amputation. Implantable peripheral nerve stimulators are another tool in the armamentarium for management of neuropathic pain. These devices have been utilized adjacent to the spinal cord and more recently in the extremities with good results, and there has been additional interest in their utility for nerve regeneration. In this case report, we present the first reported case in the readily available literature of combining contemporary peripheral nerve strategies with an implantable peripheral nerve stimulator for postamputation neuropathic pain. The patient is a 72-year-old man who presented with severe neuropathic pain following prior below knee amputation with an osseointegrated implant and regenerative peripheral nerve interfaces. The authors performed targeted muscle reinnervation with intra-operative placement of a peripheral nerve stimulator. He did well after the procedure, and his pain improved with activation of the device. The most symptomatic nerve is targeted with the nerve stimulator, and it is placed adjacent to the nerve transfer(s). Combining these contemporary techniques may lead to improved prosthetic use and quality of life for these patients.
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http://dx.doi.org/10.1097/GOX.0000000000003655DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219250PMC
June 2021

Reply: Long-Term Outcomes after Surgical Treatment of Radial Sensory Nerve Neuromas: Patient-Reported Outcomes and Rate of Secondary Surgery.

Plast Reconstr Surg 2021 07;148(1):147e-148e

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

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http://dx.doi.org/10.1097/PRS.0000000000008073DOI Listing
July 2021

Assessment of Plastic Surgery Residency Applications without United States Medical Licensing Examination Step 1 Scores.

Plast Reconstr Surg 2021 Jul;148(1):219-223

From the Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School; the Division of Plastic Surgery, University of Washington; the Department of Plastic Surgery, University of Pittsburgh Medical Center; the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine; and the Division of Plastic, Maxillofacial, and Oral Surgery, Duke University Hospital.

Summary: The United States Medical Licensing Examination announced the changing of Step 1 score reporting from a three-digit number to pass/fail beginning on January 1, 2022. Plastic surgery residency programs have traditionally used United States Medical Licensing Examination Step 1 scores to compare plastic surgery residency applicants. Without a numerical score, the plastic surgery residency application review process will likely change. This article discusses advantages, disadvantages, and steps forward for residency programs related to the upcoming change. The authors encourage programs to continue to seek innovative methods of objectively and holistically evaluating applications.
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http://dx.doi.org/10.1097/PRS.0000000000008057DOI Listing
July 2021

Hand Trauma Network in the United States: ASSH Member Perspective Over the Last Decade.

J Hand Surg Am 2021 08 15;46(8):645-652. Epub 2021 May 15.

Division of Plastic Surgery, University of Washington, Seattle, WA.

Purpose: Upper extremity trauma is common, however the provision of emergency call for hand trauma can be challenging for hospital systems and hand surgeons. Over the past decade, the American Society for Surgery of the Hand (ASSH) has developed the Hand Trauma Network and an Emergency Hand Care Committee to refine care for hand trauma patients.

Methods: The ASSH administered surveys to members about the provision of emergency hand call in 2010 and 2019. Demographic information was collected including surgeon age, years in practice, board certification, practice setting, and ACS trauma level. Other survey questions included willingness and obligation to take call, as well as barriers to providing emergency call. Financial aspects of call were also queried.

Results: Survey responses were obtained from 672 surgeons in 2010 and 1005 surgeons in 2019. There was a decrease in surgeons with obligatory hand call from 2010 to 2019 (70% vs 50%, P < .05) and an increase in the number of surgeons not taking hand call in 2019 (34%) compared to 2010 (18%, P < .05). In both surveys, the main barrier for providing hand call was "lifestyle considerations," 39% (2010) and 47% (2019). There was no change in the percentage of surgeons working at facilities that provide 24/7 emergency hand call services or the percentage of hand surgeons paid to take call.

Conclusions: Certain aspects of providing emergency hand surgery care have not changed substantially in the past decade, including the number of centers that provide emergency hand coverage. A greater number of surgeons are not taking any hand call. Further efforts are required to promulgate advances in hand trauma call by the ASSH.

Clinical Relevance: The development of the ASSH Hand Trauma Network has not yet resulted in substantive improvement in the number of facilities that provide emergency hand coverage or the number of hand surgeons providing emergency hand care.
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http://dx.doi.org/10.1016/j.jhsa.2021.03.018DOI Listing
August 2021

Gunshot Injuries of the Hand: Incidence, Treatment Characteristics, and Factors Associated With Healthcare Utilization.

Hand (N Y) 2021 Apr 22:1558944721998016. Epub 2021 Apr 22.

Massachusetts General Hospital, Boston, MA, USA.

Background: The objectives of this study are to: (1) describe the demographics, injury patterns, and treatment characteristics of patients who sustained a gunshot injury (GSI) of the hand; and (2) examine the utilization of healthcare resources in patients with a GSI of the hand.

Methods: We retrospectively identified 148 adult patients who were treated for a GSI of the hand between January 2000 to December 2017 using multiple International Classification of Diseases Ninth and Tenth Edition (ICD-9 and ICD-10) codes. We used bivariate and multivariable analysis to identify which factors are associated with unplanned reoperation, length of hospitalization, and number of operations.

Results: Multivariable logistic regression showed that fracture severity was associated with unplanned reoperation. Multivariable linear regression showed that fracture severity is associated with a higher number of hand operations after a GSI of the hand, and that a retained bullet (fragment) and patients having gunshot injuries in other regions than the hand had a longer length of hospitalization. Seventy (47%) patients had sensory or motor symptoms in the hand after their GSI, of which 22 (15%) patients had a transection of the nerve.

Conclusions: Sensory and motor nerve deficits are common after a GSI of the hand. However, only 31% of patients with symptoms had a transection of the nerve. A retained bullet (fragment), having more severe hand fractures, and GSI in other regions than the hand are associated with a higher number of operation and a longer period of hospitalization.
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http://dx.doi.org/10.1177/1558944721998016DOI Listing
April 2021

A longitudinal assessment of the surgical treatment of symptomatic neuromas and their surgical management in the American College of Surgeons National Surgical Quality Improvement Program database.

J Plast Reconstr Aesthet Surg 2021 Sep 28;74(9):2392-2442. Epub 2021 Mar 28.

Division of Plastic Surgery, Department of Surgery, Albany Medical Center, Albany, NY, United States. Electronic address:

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http://dx.doi.org/10.1016/j.bjps.2021.03.018DOI Listing
September 2021

Preparation for Hand Surgery Fellowship: A Comparison of Resident Training Pathways.

Plast Reconstr Surg 2021 04;147(4):887-893

From the Division of Plastic Surgery, Department of Surgery, Albany Medical Center; Department of Plastic Surgery, Vanderbilt University Medical Center; and Division of Plastic Surgery, Massachusetts General Hospital.

Background: Hand surgery is a unique subspecialty in which one can train after completion of either a plastic, orthopedic, or general surgical residency. This study compared hand surgery experience in residency among these different training pathways.

Methods: The Accreditation Council for Graduate Medical Education case logs of graduating residents in general surgery, orthopedics, and plastic surgery were evaluated for years 2009 through 2018. Cases were grouped according to the Accreditation Council for Graduate Medical Education-defined categories for hand surgery. Comparisons between specialties were made using a one-tail analysis of variance with a 95 percent confidence interval.

Results: There were 19,159 total residents studied: 11,189 general surgery, 7290 orthopedic, and 1040 plastic surgery. General surgery performed the fewest total hand surgeries per individual resident, while plastic surgery performed the most. Plastic surgery performed more operations than orthopedics in all categories studied including tendon, nerve, amputation, soft tissue, fracture, vascular cases, with p < 0.01 for each category.

Conclusions: There are significant differences in the preparation of resident trainees for entry into a hand surgery fellowship, and the lack of uniform exposure to hand surgery represents an opportunity for improvement. Fellowship directors and the tripartite specialty board should embrace the differences among general surgery, orthopedic, and plastic surgery graduates early in the fellowship year and address the expected differences. Trainees' education should be optimized on an individualized basis with targeted education, additional educational courses, and encouraging trainees to seek out clinical challenges to foster their continued professional growth.
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http://dx.doi.org/10.1097/PRS.0000000000007722DOI Listing
April 2021

Reset Neurectomy for Cutaneous Nerve Injuries.

Plast Reconstr Surg Glob Open 2021 Feb 15;9(2):e3401. Epub 2021 Feb 15.

Neuropax Clinic, St. Louis, Mo.

Diffuse cutaneous nerve injuries, often caused by a crush mechanism, are challenging for the nerve surgeon. Discrete nerve transections and focal neuromas are easier to identify and have a more distinct treatment algorithm. Following crush injury to a noncritical sensory nerve, a successful local anesthetic block proximal to the injury may help determine the possibility of surgical intervention. In these cases, we describe a technique of "reset neurectomy" whereby a neurectomy is performed proximal to the zone of injury, and immediate repair or reconstruction (with or without a nerve graft) is performed. This technique may be useful in cases of diffuse, nontransection nerve injuries in which neuropathic pain is the primary symptom.
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http://dx.doi.org/10.1097/GOX.0000000000003401DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929540PMC
February 2021

Interdisciplinary Care for Amputees Network: A Novel Approach to the Management of Amputee Patient Populations.

Plast Reconstr Surg Glob Open 2021 Feb 15;9(2):e3384. Epub 2021 Feb 15.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Mass.

Extremity amputation remains a common intervention for limb-threatening conditions. With advancement in surgical technique to address deleterious postoperative sequelae of limb removal, there is a salient need to develop and operationalize interdisciplinary care frameworks to provide more comprehensive care to an otherwise challenging patient population. Herein, we describe our interdisciplinary approach to the management of amputee patient populations at our institution, referred to as the Interdisciplinary Care for Amputees Network (ICAN). This novel framework focuses on 3 fundamental areas: combined preoperative patient evaluation, orthoplastic surgical intervention, and multi-specialty postoperative functional and psychosocial rehabilitation. Importantly, the successful implementation of a combined orthoplastic clinic requires establishing a working relationship among providers to leverage increased provider familiarity. This, coupled with sufficient clinic space, dedicated operating room time, and standardized patient workflow, serves to improve care and meet patient goals of pain minimization, return to desired functional status, and improvement in quality of life.
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http://dx.doi.org/10.1097/GOX.0000000000003384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929623PMC
February 2021
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