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Osteoarthritis of the trapeziometacarpal joint is common. There are limited surgical options for patients who have undergone a failed primary trapeziometacarpal arthroplasty. The authors conducted a retrospective review of patients who received a porcine dermal graft for failed trapeziometacarpal arthroplasty. Three hundred fifty-five trapeziometacarpal procedures were performed from 2005 to 2015; 9 were revisions. Seven were performed with xenograft interposition. Data included primary procedure, grip and key pinch strength, Visual Analog Score (VAS), motion, time to return to work, Kapandji Score, and radiographs. The mean follow-up was 84 weeks. The mean VAS score was 2.3, and all patients reported notable improvement. The mean Kapandji Score was 8. The mean grip was 20 kg, and the mean key pinch was 5 kg in the operated hand. The mean time to return to work was 12 weeks. The final radiographs showed improvement in spaces. No complications or immunological reactions were encountered. The authors describe a technique for revision trapeziometacarpal arthroplasty with a porcine xenograft acellular dermal matrix. This technique shows a safe and valid treatment option with acceptable clinical outcomes.

Achieving a vascularized granulation bed is essential prior to split-thickness skin grafting (STSG) but is often protracted with existing dermal substitutes. Porcine-derived extracellular matrix (pECM) powder (XCelliStem Wound Powder; StemSys) supplies structural proteins and growth factors that may shorten this interval. Three adults with complex wounds-a traumatic dorsal-foot defect, a cervical burn contracture reconstructed with a latissimus flap, and a free omental flap to an upper-extremity degloving injury-received intraoperative application of hydrated pECM powder following meticulous debridement. Wounds were covered with Xeroform and either hypochlorous-soaked gauze or negative pressure wound therapy. Granulation, exudate, and infection were assessed daily; STSG was performed once a uniform, vascular bed formed. Patients were followed for ≥3months. Complete, healthy granulation tissue developed on post-application days 9, 11, and 13, respectively, enabling timely STSG. All grafts achieved 100% take without necrosis, seroma, or infection. At 3 months, each site displayed durable coverage, preserved function, pliable scars with preserved elasticity, and high patient satisfaction. In this preliminary series, pECM powder accelerated wound bed readiness and supported reliable STSG within 2 weeks-substantially faster than the 3- to 7-week intervals reported for Integra Bilayer Matrix (Integra LifeSciences Corp) and NovoSorb Biodegradable Temporizing Matrix (PolyNovo Ltd). The pECM powder appears safe, easy to apply, and may reduce morbidity and resource use; controlled trials are warranted.

Oronasal fistula (ONF) repair remains a significant challenge in patients with cleft lip and palate, particularly when local palatal tissue is insufficient. Regional flaps, including the buccal myomucosal flap (BMMF) and the facial artery musculomucosal (FAMM) flap, offer reliable reconstructive options. This study reviews the surgical anatomy, design, and clinical outcomes of these buccinator-based flaps in ONF repair. This retrospective case series included 13 patients who underwent ONF repair using a BMMF or a FAMM flap between 2017 and 2024. Patient demographics, fistula characteristics, surgical details, postoperative care, and outcomes were collected and analyzed. Six patients underwent BMMF reconstruction, while 7 received FAMM flaps. Successful fistula closure was achieved in 66.7% of patients in the BMMF group, with flap dehiscence occurring in 2 cases, both associated with digital manipulation. The FAMM flap cohort had a 100% fistula closure rate but exhibited a high incidence (86%) of postoperative scar contracture, with 4 patients requiring contracture release. Based on this experience, the authors propose an algorithm for flap selection in ONF repair. Posteriorly based BMMFs are well suited for fistulas at the junction of the hard and soft palate (Type III) and the posterior third of the hard palate (Type IV). Superiorly based FAMM flaps are preferred for anterior ONFs, particularly those extending into the alveolus. The central hard palate remains a reconstructive challenge, with FAMM flaps offering better reach, though they require staged inset and debulking. Both BMMF and FAMM flaps provide vascularized tissue for ONF closure with minimal donor site morbidity. Strategic flap selection based on fistula location optimizes outcomes while mitigating complications.

Trickle charging is a process by which an external power supply is used to maintain charge in a battery. When applied to flaps, trickle charging allows temporary perfusion of the flap (battery) by using a perforator that is discontinuous from the main pedicle (external power supply), allowing main pedicle ligation. Two procedures that benefit from this technique are the conventional open bilateral deep inferior epigastric perforator (DIEP) flap and the robotic bilateral DIEP flap. In the conventional open bilateral DIEP flap, trickle charging is used to improve perioperative efficiency. In the event that the recipient site is not ready for flap transfer (ie, mastectomy and/or chest vessel preparation are not completed), trickle charging enables the main pedicle to be harvested from the intraabdominal cavity. This facilitates early rectus fascia and partial abdominal closure. In a bilateral robotic DIEP flap, trickle charging allows the second hemi-abdominal flap to maintain perfusion after the main pedicles in the intra-abdominal cavity are robotically harvested. Both scenarios demonstrate the possibility of temporary perfusion of the flap, despite the main pedicle being ligated. Sixteen total patients had hemi-abdominal flaps that were trickle charged (5 conventional, 11 robotic). All the flaps were tested for proper perfusion intraoperatively using multiple different modalities. None of the patients experienced total flap loss, partial flap loss, or fat necrosis. The authors review the safety of trickle charging in consecutive robotic and open bilateral DIEP flap breast reconstructions. This technique can be easily replicated for various other flaps with the help of preoperative computed tomography or magnetic resonance angiography to identify main pedicle vessels and an alternative temporary perforator.

Alligator bites are a rare occurrence, though some literature on injurious human-alligator interactions exists. This report details 3 cases of alligator bite-related wounds with characteristic extensive tissue damage and subsequent reconstruction. We also review the literature on caring for this specific population. The authors present a systematic literature review on alligator bite-related sequalae and care. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed throughout the systematic literature review. The authors also present a case series of patients wounded by alligators who each presented to a large tertiary academic center on the west coast of Florida. Early debridement, prophylactic antibiotics, soft tissue reconstruction, and interdisciplinary care are the main tenets of care for patients who sustain alligator bites. Case 1 was a 53-year-old man with a left upper extremity bite with significant neurovascular damage and near transradial amputation who underwent emergent revascularization. After multiple attempts at limb salvage, the patient underwent formal transradial amputation. Case 2 was a 77-year-old woman with bites to her left upper and lower extremities, with concern for lower extremity Morel-Lavallée lesion. The lower extremity wound was reconstructed with lateral gastrocnemius muscular and fibularis longus musculocutaneous flaps and split-thickness grafting; ultimately, transradial amputation was necessary for the upper extremity after evidence of devascularization. Case 3 was a 34-year-old man with a facial injury and skull fracture. After initial operative repair of the facial nerve and soft tissue lacerations, the patient required later revision with cranioplasty and temporalis coverage because of a draining wound. All 3 patients survived their severe injuries. This case series represents a unique set of patients maimed by alligators and their subsequent surgical management. Recommendations from the literature review include an interdisciplinary approach, early operative investigation and initiation of broad-spectrum antibiotics, and to consider a staged reconstruction for these injuries.

The opioid crisis continues to be a significant public health concern in the United States, with postoperative prescriptions contributing to the problem. Older adults face increased risks from opioid use, yet prescribing practices for hand surgery in the Medicare population remain understudied. This research aims to elucidate opioid prescription patterns among hand surgeons treating Medicare patients, focusing on national trends, regional variations, and gender differences. A retrospective analysis was conducted using data from the Centers for Medicare and Medicaid Services Medicare Part D Prescription Drug Program Prescribers Public Use File for hand surgeons from 2015 to 2019. National trends, regional variations based on US Census Bureau divisions, state-level differences, and gender disparities in opioid prescribing patterns were examined. Key metrics included opioid prescribing rates, proportion of opioid claims to total claims, average prescription duration, and total opioid claims per surgeon. From 2015 to 2019, a total of 1752 hand surgeons were identified in the Medicare Part D database with a 5-year average of 231 405 opioid claims, comprising 53% of all claims made by hand surgeons. The median opioid prescribing rate decreased from 61.4% in 2015 to 55.3% in 2019. The proportion of opioid claims to total claims fell from 55.4% to 48.27%, and the average prescription duration decreased from 6.3 to 4.67 days. Significant regional and state-level variation was identified. Overall, the South had higher numbers of opioid prescriptions per hand surgeon and prescribed for more days compared with all other regions, but the Midwest and West regions had larger proportions of opioid claims. Despite an overall decrease in opioid prescribing by hand surgeons for Medicare patients from 2015 to 2019, significant regional and gender-based variations persist. These findings underscore the need for standardized guidelines, improved prescriber education, and better integration of monitoring programs.

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There is not a singular "gold standard" therapy for managing surgical wound dehiscence (SWD); rather, the goal is expediting wound closure. This study examines the feasibility of using a continuous topical oxygen (cTOT) device as part of a treatment algorithm to treat SWD of the lower extremity. A single-center, retrospective analysis of lower-extremity SWD treated with cTOT was conducted via a retrospective chart review. Data were collected for a period of 8 months from January to August 2024. All SWD received the standard of care in addition to cTOT. Patients were seen weekly for evaluation until complete wound closure. Nine patients were included in this case review. The mean patient age was 52.6 years. SWD occurred after a variety of interventions. All patients' SWD grade was either 3 or 4 according to the World Union of Wound Healing Society Sandy Grading System. The average time from starting TOT to the SWD healing was 52.6 days. In addition, the average estimated SWD surface area based on the wound measurement at the start of delivering TOT was 19.5 cm2. The average time to wound healing for all patients was 70 days. After excluding 1 outlier, the average time to wound healing was 59.5 days. The positive outcomes exhibited in this case series suggest that cTOT is an effective treatment in the management of SWD in patients, regardless of specific surgical intervention. Furthermore, all the SWDs treated with cTOT progressed to wound closure without further need for surgery, hospitalization, or other costly procedures.

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Porphyromonas (P.) species, typically associated with oral infections, are known for their role in causing root canal infections and endodontic abscesses. Here, the authors present the first and only reported case of P. endodontalis osteomyelitis in a long bone following a phalanx injury and subsequent dental procedure. In this case, the infection presented in the right fifth proximal phalanx of a 16-year-old boy. Despite initial conservative management and multiple negative bacterial cultures, symptoms persisted, prompting surgical intervention with debridement, biopsy, culture, and polymerase chain reaction analysis. This case underscores the aggressive and elusive nature of P. endodontalis, highlighting challenges in diagnosis and the importance of considering the Porphyromonas species in cases of osteomyelitis, particularly in those with a dental history.

Masculinizing (female-to-male) gender-affirming bottom surgeries (GABS) commonly include hysterectomies and can be performed in a staged manner or at the time of masculinizing genital surgery. Prior studies with small patient cohorts have suggested that adopting a combined approach increases the likelihood of complications. This study aimed to characterize patients undergoing gender-affirming masculinizing genital surgery with and without concurrent hysterectomies and determine whether there were additive risks of concurrent procedures. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients with International Classification of Diseases-9/-10 gender dysphoria diagnoses who underwent masculinizing GABS (intersex for female to male, simple or complex scrotoplasty) from 2012 to 2022. Stratified by the presence of a concurrent hysterectomy, baseline characteristics, preoperative commodities, and 30-day postoperative outcomes were compared between single-stage GABS and those with concurrent hysterectomy. Of the 113 total patients included, 83 (73.5%) patients had a single-stage GABS and 30 (26.6%) patients had a GABS combined with hysterectomy. Baseline characteristics, including age, gender distribution, and preoperative comorbidities, were comparable between groups. The median operative time and hospital length of stay were similar between groups. However, single-stage GABS patients had higher rates of return to the operating room (14.5% vs 0.0%, P = .03), wound complications (22.9% vs 0.0%, P = .004), and all-cause complications (27.7% vs 6.7%, P = .02). The results suggest that performing hysterectomies at the time of masculinizing GABS can be safe in appropriately selected patients. These findings highlight the potential safety benefits of combining GABS with hysterectomy and underscore the need for further research into optimizing outcomes for diverse patient populations, as a combined approach may improve efficiency, aid access to care, and improve patient satisfaction.

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Severe traction injury to the brachial plexus (BP) during childbirth can induce the formation of intraneural scar tissue or neuroma in continuity. This can lead to nerve entrapment and demyelination, which inhibit axonal transport to the target muscles. Secondary complications include muscle weakness, contractures, joint deformity, and altered limb growth with prolonged and persistent disability. These patients find difficulty performing activities of daily living. BP neurolysis is one of the multistage reconstructive procedures in patients with obstetric brachial plexus injury (OBPI). The successful outcome of BP neurolysis is reported in patients with OBPI. We report improvements in all Mallet functional movements, including forearm supination angle (the Nath-modified Mallet), in 40 OBPI patients after BP neurolysis. Forty OBPI patients (25 female and 15 male with a mean age of 14 years, range 2-25 years; 29 on the right and 11 on the left) underwent BP neurolysis and follow-up evaluations with the lead author and surgeon (RKN). All these patients had undergone multiple previous surgeries, such as primary exploration, Botox, nerve transfer, humeral or forearm osteotomy, wrist tendon transfer, mod Quad, triangle tilt, and biceps tendon lengthening. Patients' pre- and postoperative shoulder functions were evaluated by the surgeon in the clinic and from photos/videos. These functional movements include shoulder abduction, external rotation, hand-to-mouth movement, hand-to-neck movement, and hand-to-spine movement, which score from 1 (no movement) to 5 (normal movement). In addition to the Mallet functional movements, the supination angle (the angle between the midline of the body and the tangential line to the palm with arms straight; neutral = 0, full supination = 90&#xb0;, full pronation = -90&#xb0;) was also evaluated and scored using the Nath-modified Mallet before and after BP neurolysis. Of the 40 patients in this report, 37 (93%) achieved a Mallet grade of 5/5 (n = 23, 58%) or 4/5 (n = 14, 35%) in shoulder abduction after BP neurolysis. The other 3 patients had a Mallet grade of 3/5 (90 degrees) postoperatively in shoulder abduction. There was statistically highly significant improvement after BP neurolysis in shoulder abduction (3.9 &#xb1; 0.7 to 4.5 &#xb1; 0.6, P < .0001), external rotation (2.9 &#xb1; 1.0 to 3.8 &#xb1; 1.1, P < .0001), hand-to-mouth (4.2 &#xb1; 0.7 to 4.5 &#xb1; 0.7, P < .03), hand-to-neck (3.6 &#xb1; 0.8 to 4.2 &#xb1; 0.8, P < .0001), hand-to-spine (2.9 &#xb1; 1.1 to 3.4 &#xb1; 1.2, P < .004), forearm supination (3.8 &#xb1;1.1 to 4.2 &#xb1;1.0, P < .0001), the Nath-modified total Mallet score (21 &#xb1; 3.1 to 25 &#xb1; 3.3, P < .0001), including supination angle (40.5 &#xb1; 48.8 to 56.3 &#xb1; 41.6, P < .001). Improvement in the Nath-modified total Mallet functions was weakly associated with follow-up time after BP neurolysis (R = 0.17, P = .0003). Among the 40 patients, 37 (93%) achieved a Mallet grade of 5/5 or 4/5 in shoulder abduction after surgery with a mean follow-up of 2 years. All upper-limb functional movements improved significantly as BP neurolysis improves axonal transport to the target muscles after surgically removing the external and internal scarring of the upper trunk and its terminal branches. Additionally, neurolysis decompresses the BP from external compression by the surrounding connective tissues and densely scarred scalene muscles. Thus, it can provide these patients with an effective and rapid functional recovery. These children and their parents are pleased with the progress and increased ability to perform their activities of daily living after surgery.

Restoration of a stable and functional soft tissue envelope following traumatic injury to the musculoskeletal system is critical. Where primary closure is not feasible, other reconstructive options must be considered to achieve soft tissue coverage of critical structures. Skin substitutes have been utilized to stimulate granulation tissue and support incorporation of autografts. This present study aims to investigate the use of a fully synthetic electrospun fiber matrix (SEFM) (Restrata; Acera Surgical, Inc) in the management of post-traumatic soft tissue defects. The objective of the present retrospective case series was to assess healing outcomes, including time to healing and incidence of complications, following a single application of the SEFM to soft tissue trauma surrounding musculoskeletal injury. Medical charts of patients with soft tissue injury secondary to musculoskeletal trauma and who were treated with the SEFM in the operating room following bony instrumentation or fasciotomy procedures were retrospectively reviewed following institutional review board approval. Included patients were treated with the SEFM in conjunction with negative pressure wound therapy as a means of preparing open wounds for definitive management via split-thickness skin grafting or secondary intention healing. Eleven patients met the inclusion criteria. Injury etiologies included 8 open fractures in both upper and lower extremities, 2 open foot-crush injuries, and 1 incidence of forearm compartment syndrome. Ten patients achieved complete healing with minimal complications. Preliminary results indicate that the SEFM may be a viable adjunctive treatment for open post-traumatic wound beds to promote granulation tissue for definitive closure.

Patients undergoing facial plastic surgery are increasingly using artificial intelligence (AI) to visualize expected postoperative results. However, AI training models' variations and lack of proper surgical photography in training sets may result in inaccurate simulations and unrealistic patient expectations. This study aimed to determine if AI-generated images can deliver realistic expectations and be useful in a surgical context. The authors used AI platforms Midjourney (Midjourney, Inc), Leonardo (Canva), and Stable Diffusion (Stability AI) to generate otoplasty, genioplasty, rhinoplasty, and platysmaplasty images. Board-certified plastic surgeons and residents assessed these images based on 11 metrics that were grouped into 2 criteria: realism and clinical value. Analysis of variance and Tukey Honestly Significant Difference post-hoc analysis tests were used for data analysis. Performance for each metric was reported as mean &#xb1; SD. Midjourney outperformed Stable Diffusion significantly in realism (3.57 &#xb1; 0.58 vs 2.90 &#xb1; 0.65; P < .01), while no significant differences in clinical value were observed between the AI models (P = .38). Leonardo outperformed Stable Diffusion significantly in size and volume accuracy (3.83 &#xb1; 0.24 vs 3.00 &#xb1; 0.36; P = .02). Stable Diffusion underperformed significantly in anatomical correctness, age simulation, and texture mapping (most P values were less than .01). All 3 AI models consistently underperformed in healing and scarring prediction. The uncanny valley effect was also observed by the evaluators. Certain AI models outperformed others in generating the images, with evaluator opinions varying on their realism and clinical value. Some images reasonably depicted the target area and the expected outcome; however, many images displayed inappropriate postsurgical outcomes or provoked the uncanny valley effect with their lack of realism. The authors stress the need for AI improvement to produce better pre- and postoperative images, and plan for further research comparing AI-generated visuals with actual surgical results.

Anocutaneous and rectocutaneous fistulas are associated with high morbidity and mortality, and complex fistulas often pose challenges to surgical repair. Here, the authors report a case of a rare 7-cm extrasphincteric fistula that extended from the base of the phallus to the external anal canal in a patient with a history of scrotal reconstruction after Fournier gangrene. Despite the anterior location of the cutaneous sinus tract and initial concern for penile urethral involvement, intraoperative instillation of methylene blue revealed a long extrasphincteric anocutaneous fistula. With colorectal surgery co-involvement, the mature tract was dissected free from the urethra, base of the penis, and scrotum, and redirected inferiorly and diverted to a new position anterior to the anal sphincter complex. This technique created a significantly shorter tract that salvaged the scrotal reconstruction, preserved the sphincter complex, and minimized risk of infection to the scrotal reconstruction. This novel technique can be used as either a temporary or permanent solution to complex mature fistulas in high-risk patients.

Burned hands require special attention and prompt treatment because of their vital functional importance. With fluorescein dye, it is possible to visualize vascular dermal layers to assist with the removal of nonviable skin through tangential excision. Within 24 to 48 hours after a burn, 5 mg of fluorescein dye was injected intradermally and a Wood light was used to determine burn depth. Under anesthesia, an Air Brown (Zimmer Biomet) or castroviejo dermatome and a free-hand or Humby knife was used to excise the burned skin. Split-thickness layers approximately 0.015 inches thick were removed until strong fluorescence was noted. Observation indicators were used to assess the quality of the skin graft outcomes. No cases of infection, seromas, hematomas, or contractures were seen. Additionally, patients experienced reasonable cosmetic and functional outcomes within weeks to months following grafting. Excision and split-thickness skin grafting with fluorescein dye and tangential excision can achieve desirable results and restore both cosmetic and functional outcomes.

The treatment of complex wounds remains a challenging aspect of reconstructive surgery, given their diverse nature and the frequent need for high-level surgical procedures. Standard treatment with flap coverage can achieve many goals; however, it is not without difficulties, including technical complexity, extended recovery times, donor site morbidity, and vascular complications, particularly in non-optimized patients. Acellular extracellular matrices, such as porcine urinary bladder matrices, have emerged as an alternative approach to support wound healing without the risks of high-level reconstruction. Urinary bladder matrix provides an extracellular matrix scaffold that supports intrinsic tissue regeneration mechanisms, allowing for stable, well-vascularized wound bed formation. This retrospective case series examines the outcomes of urinary bladder matrix for the treatment of complex wounds in 21 patients deemed high-risk or unfavorable candidates for surgical management with local or free flap techniques. The patients were treated by 2 surgeons at 2 separate level 1 trauma centers from October 2019 through June 2022. Urinary bladder matrix was the primary wound management modality with serial wound debridement, matrix reapplication, and subsequent wound care tailored to each patient until definitive, stable coverage. In all cases, urinary bladder matrix facilitated soft tissue remodeling, permitting complete wound re-epithelization or preparation for skin grafting and/or flap coverage. Four patients' wounds re-epithelized on their own, while 17 patients received subsequent skin graft. In 2 of these cases, the initial split-thickness skin graft failed, requiring a second skin graft and or/flap coverage. Our results demonstrate that urinary bladder matrix facilitates definitive soft tissue reconstruction and can be a valuable adjunct to wound repair, providing a simpler, less morbid treatment option for patients with various comorbidities and injury mechanisms.

Breast reconstruction following mastectomy commonly involves tissue expanders to create a suitable pocket for implantation. The use of triple antibiotic irrigation during tissue expander placement aims to reduce implant-related infections. Implant infections can lead to severe complications, often necessitating revision surgeries that may delay treatment of other conditions, such as cancer. For years, the most common solution used in breast pocket irrigation was the Adams solution, which comprises 80 mg gentamicin, 1 g cefazolin, and 50 000 U bacitracin in 500 mL of normal saline. However, the discontinuation of bacitracin has prompted the search for alternative formulations. Vancomycin, like bacitracin, has been shown to provide gram-positive coverage-only better. This study aims to evaluate the utility of a triple antibiotic solution (TAS) containing gentamicin, cefazolin, and vancomycin as a replacement for bacitracin in reducing infection rates following tissue expander placement. A single-center retrospective chart review was conducted, including 152 patients who underwent a total of 277 breast reconstructions with a TAS comprising 80 mg gentamicin, 1 g cefazolin, and 1 g vancomycin from March 2020 to June 2024. Demographic and clinical data, perioperative characteristics, and postoperative outcomes-including infection rates and culture results-were analyzed. Infections occurred in 6 of 277 reconstructions (2.17% of implants). Methicillin-resistant Staphylococcus aureus was a significant pathogen in infections (50.00%). None of the systemic side effects of vancomycin, including nephrotoxicity, ototoxicity, or vancomycin flushing syndrome, were encountered. Furthermore, no evidence of drug-resistant bacteria was reported in any of the cases. This study highlights the potential utility of vancomycin as an acceptable alternative to bacitracin in triple antibiotic irrigation solution following tissue expander placement post-mastectomy. Additional research could help to further establish vancomycin's efficacy and safety. If validated, this approach could be a temporary alternative to the Adams solution until a better long-term strategy is identified.