Arriyan Samandar Dowlatshahi

Background: Soft tissue defects around the knee are a commonly encountered surgical scenario, with the gastrocnemius muscle flap having emerged as a reliable option due to its proximity, versatility, and consistent vascular supply. However, excessive tension during flap inset can lead to wound complications, delaying mobilization and limiting early postoperative rehabilitation. We introduce a technique for flap inset using intraoperative injection of botulinum toxin A (BTX-A). Materials and Methods: A retrospective case series of four female patients (mean age: 49 y, range: 36–58) undergoing gastrocnemius muscle flap reconstruction for knee soft tissue defects was performed. Intraoperatively, 100 units of BTX-A diluted in 10 mL of normal saline were injected into the gastrocnemius muscle belly before flap inset using a 30-gauge needle. Indications included anticipated tight inset, concern for patient compliance, or planned early mobilization. Early range of motion and weight-bearing were initiated between postoperative days 2 and 7. Institutional review board approval was obtained. Results: All four patients achieved complete wound healing without flap dehiscence or other complications. Early mobilization and weight-bearing were tolerated in all cases. No adverse events related to BTX-A administration were observed. Conclusion: Intraoperative BTX-A injection into the gastrocnemius muscle flap may facilitate tension-free inset and enable early postoperative mobilization without compromising wound healing. This technique could represent a useful adjunct in high-risk reconstructions where delayed mobilization is undesirable.

Soleal sling syndrome (SSS) is an underdiagnosed cause of tibial nerve (TN) entrapment at the popliteal fossa. It is characterized by TN compression beneath the tendinous arch of the soleus muscle,...

Background: Extensor pollicis longus (EPL) rupture can be managed using several surgical techniques, with palmaris longus (PL) tendon graft reconstruction and extensor indicis proprius (EIP) transfer among the most commonly used options. Comparative clinical data between these techniques remain limited, particularly regarding functional outcomes and delayed reconstruction. This retrospective cohort study evaluated functional outcomes and complications following EPL reconstruction using a PL graft or EIP transfer in a single-institution cohort. Methods: This retrospective cohort study included demographic, surgical, and outcome data of all patients who presented to our institution with an EPL rupture between 2004 and 2020. Patients were identified using Current Procedural Terminology codes, International Classification of Diseases, Ninth/Tenth Revision codes, and operating room schedules. Group comparisons were performed using Fisher exact test, χ ² test, and t test, as appropriate; P < .05 was considered statistically significant. Results: A total of 38 patients with EPL rupture were identified, including 8 treated with PL grafts and 30 with EIP transfer. Both groups demonstrated improvement in Disabilities of the Arm, Shoulder, and Hand (DASH) scores. The PL graft group showed a larger mean reduction in DASH scores. Three patients in the EIP transfer group (11%) experienced index finger extensor lag or limited EPL function, whereas no such cases occurred in the PL graft group. Conclusion: Both PL graft reconstruction and EIP transfer were associated with postoperative functional improvement in this cohort. Although the PL graft group demonstrated a larger mean reduction in DASH scores, the marked differences in baseline characteristics and surgeon-directed treatment selection preclude firm comparative conclusions. Delayed PL graft reconstruction was nevertheless associated with acceptable postoperative outcomes in this series.

Background: Surgical disparities often stem from social determinants beyond underlying pathology. This study aims to examine how race, socioeconomic factors, and insurance status affect the management of trigger finger, one of the most common hand conditions treated in the United States. Methods: We retrospectively identified 2639 patients diagnosed with trigger finger using International Classification of Diseases and Current Procedural Terminology codes from the electronic medical record between 2015 and 2020. Descriptive statistics summarized demographic and clinical characteristics. Bivariate logistic regression assessed associations between socioeconomic indicators, including insurance type and education, and the likelihood of undergoing surgical versus nonoperative treatment. Variables meeting clinical or statistical criteria were included in a multivariable logistic regression model. Adjusted odds ratios with 95% confidence intervals were reported. Statistical significance was set at P < .05. Results: Among 2639 patients, 16.2% underwent surgical release and 1.7% required multiple procedures. The mean age was 62.0 ± 12.7 years. Age, race, and insurance type were independently associated with surgical treatment. Asian/Pacific Islander patients had lower odds of surgery compared with White patients (6.8% vs 15.7%). Patients insured through Medicare or without insurance were less likely to undergo surgery than those with private insurance or workers’ compensation (11.6% vs 17%). Education level, sex, primary language, body mass index, and comorbidities were not independently associated with surgical treatment. Conclusion: Although trigger finger management is typically streamlined, age, race, and insurance status influence treatment pathways. These findings suggest that socioeconomic factors may influence access to definitive surgical care.

Case: We present a 59-year-old male patient with recurrent right knee extensor mechanism deficiency who underwent reconstruction using a free vascularized tensor fascia lata flap from the ipsilateral thigh with submillimeter perforator-to-perforator anastomosis. Performed in a revisional setting (third surgery) with scarring and prior failure, novel aspects included dual-layer reinforcement and limited-incision harvest with tunneling. At 12 months, he regained full extension and a stable, pain-free gait. Conclusion: This case shows that a free vascularized tensor fascia lata flap with perforator-to-perforator anastomosis is a viable option for extensor mechanism reconstruction in complex, revisional cases.

In hand trauma, the uninjured forearm has been touted as the ideal site for ectopic banking in digit/hand amputations. Here, we describe the temporary ectopic implantation and subsequent replantation of a partially amputated hand and highlight the “Three R’s” – Recovery, Rehabilitation, and Revision over the first year of recovery.

Background: Postamputation pain is a debilitating sequela of upper extremity (UE) amputation. Targeted muscle reinnervation (TMR) is a relatively novel treatment that can help prevent pain and improve quality of life. The purpose of this study was to evaluate national trends in the application of immediate TMR following UE amputations. Methods: An analysis of the Nationwide Inpatient Sample database was conducted from 2016 to 2019. International Classification of Diseases, 10th Revision, codes were used to identify encounters involving UE amputation with and without TMR. Nationwide Inpatient Sample weights were used to estimate national estimates of incidence. Patient-specific and hospital-specific factors were analyzed to assess associations with use of TMR. Results: A total of 8945 weighted encounters underwent UE amputation, and of those, only 310 (3.5%) received TMR. The majority of TMR occurred in urban hospitals (>95%). Younger patients (47 years versus 54 years; P = 0.008) and patients located in New England were significantly more likely to undergo TMR. There was no difference in total cost of hospitalization among patients who underwent TMR ($55,241.0 versus $59,027.8; P = 0.683) but significantly shorter lengths of hospital stay when undergoing TMR versus other management (10.6 days versus 14.8 days; P = 0.012). Conclusions: TMR has purported benefits of pain reduction, neuroma prevention, and increased prosthetic control. Access to this beneficial procedure following UE amputation varies by demographics and geographic region. Given that TMR has not been shown to increase cost while simultaneously decreasing patient length of stay, increased efforts to incorporate this procedure into training and practice will help to ensure equitable care for amputation patients.