Scientific Abstract Presentations: Hand Session 4 Friday, September 27 Fri, Sep 27 2:00-3:30 p.m. PDT

Introduction:

Injuries of the digital collateral ligaments are common and most frequently involve the thumb metacarpophalangeal (MCP) joint. The thumb MCP joint ulnar collateral ligament (UCL) is at particular risk with either chronic radial deviation forces or by an acute hyperabduction mechanism.

Historically, ligament repair was performed either by direct repair/reinsertion or reconstruction with an autologous tendon graft. The use of suture tape (e.g. Internal Brace™ [IB]) is a relatively new technique availble to augment repair of the thumb MCP joint UCL. Evidence indicates that suture tape provides biomechanical support to allow for more rapid rehabilitation and return to activities. There is no consensus best surgical practice for UCL repair and reconstruction, and the utilization of suture tape techniques are not well understood. In this study, we sought to assess the practice patterns amongst American Society of Surgery of the Hand (ASSH) members.

Methods:

This research study is an on going national survey assessing the surgical management of thumb MCP joint UCL injuries. Institutional IRB was obtained. A comprehensive 17-question survey was created using Qualtrics (Qualtrics, Provo, UT). After submission and approval from the ASSH, a contact list containing all surgeon members was obtained. The survey was emailed January of 2024. This dataset represents a 1-month snapshot of our ongoing three-month survey. Qualtrics was utilized for survey analysis.

Results:

A total of 312 surgeons responded to the survey (9% response rate). Respondents were orthopedic surgeons (264/312, 84.6%), plastic surgeons (37/312, 11.9%) and general surgeons(11/312, 3.5%). The majority (235/312, 75.6%) had been in practice for at least 5 years. 62.8% (196/312) reported performing 5-15 UCL repairs /reconstructions per year.

When treating the digital collateral ligament (thumb MCP joint UCL), if there is sufficient remaining ligament for repair, only 0.6% (2/312) surgeons performed repair with suture tape only, while 48.4% (151/312) performed direct repair with suture tape augmentation, and 50.3% (157/312) performed direct or suture repair. If there is not sufficient ligament for repair, 18.6% (58/312) performed repair with suture tape only, 56.1% (175/312) performed autologous graft with suture tape augmentation, and 21.8% (68/312) performed reconstruction with autologous graft only. The majority of respondents (200/312, 65.2%) stated the biggest concern with using suture tape alone for UCL repair/reconstruction is instability/long-term durability.

Conclusion:

This is the first study attempting to understand current practice in management of digital collateral ligament injuries. These data indicate that suture tape is widely utilized for UCL injuries, especially in cases where there is not sufficient ligament for repair.

Background Segmental defect reconstruction of upper extremity diaphyseal defects (UEDDs) can be managed with multiple techniques. While free vascularized bone flaps (VBF) have been well characterized for treating large segmental defects, much of the literature is broad and lacks adequate granularity to inform clinical decision-making in the upper extremities. In this study, we sought to characterize and summarize the available literature on VBF reconstruction for UEDDs.

Methods A scoping review was conducted using PRISMA-ScR guidelines on major databases. Inclusion criteria included patient-level data on upper extremity diaphyseal segmental defects of the radius, ulna, or humerus reconstructed with free vascularized bone flaps requiring microsurgical anastomosis. Exclusion criteria included non-diaphyseal reconstructions, non-upper extremity defects, non-vascularized reconstructions, review articles, and outcomes studies without patient-level data. In Python, descriptive statistics and unadjusted odds ratios were calculated for primary union and each complication using surgical indications as exposure events.

Results Overall, 3,122 articles were screened to identify 54 eligible studies comprising 364 patients. Indication for reconstruction was atrophic non-union in 125 (34.3%) patients, post-oncologic in 125 (34.3%), septic non-union in 56 (15.4%), and acute trauma in 36 (15.4%). The free fibula flap (FFF) was the most utilized vascularized bony graft, constituting 272 (74.7%) reconstructions. The medial femoral condyle (MFC) (69, 19.0%) and scapular (8, 2.2%) flaps were the next most used. Mean defect size was 8.53±5.14cm, recipient vessels were most commonly brachial (41, 32.8%) or radial (27, 21.6%) arteries, and plates with screws (73, 58.4%) were the most used form of fixation. Primary union was achieved in 317 (87.1%) cases within 6.03±4.19 months. Delayed union (29, 8.0%), malunion (4, 1.1%), reoperation (61, 16.8%), and non-union (18, 5.0%) were observed in a minority of patients. Graft fractures were over fivefold more likely with oncologic etiologies (OR=5.5, 95% CI=1.46-20.76).

Conclusions VBFs demonstrate excellent reconstructive outcomes characterized by high primary union rates. FFF is the most utilized VBF for reconstructing UEDDs, particularly for spanning large defects >6cm and hostile wound beds. The length and architecture of the bone make it a "like-for-like" match with the radius and ulna. MFC flaps are optimal for smaller defects <6cm, with thin, pliable geometry that makes them suitable for extra-articular bony reconstruction. The MFC flap is well-poised for use in recalcitrant non-unions and hostile wound beds, posting high union rates in this study. A size demarcation of 6cm should be adopted when deciding between FFF and MFC flaps.

BACKGROUND: Constriction band syndrome (CBS) has rarely been associated with congenital peripheral nerve hypoplasia (CPNH) which can significantly impair motor function of the upper extremity. Prior case reports suggest that constriction band release between 3 months and 5 years of age are largely unsuccessful;(1,2) the few cases demonstrating neurologic recovery involved constriction band release with nerve decompression at 1 week,(3) 3 weeks,(4) and 14 weeks of life.(5) Thus, Mohan et al. suggest that intervention performed within the first month of life provides the best chance of motor recovery in cases of CPNH associated with CBS.(3) PURPOSE: We present two case reports of CPNH associated with CBS and conduct a literature review supporting the practice of early intervention, even within the first few hours of life. METHODS: Case 1 is a male infant who was born with a left upper extremity constriction band causing venous congestion with concern for vascular compromise, compartment syndrome, and ulnar and median motor palsies. He was operated on emergently at 3 hours of life for complete excisional constriction band release with z-plasty, brachial artery exploration, forearm fasciotomies, and decompression of median and ulnar nerves. Intra-operative findings were notable for hourglass constriction of the median and ulnar nerves. Case 2 is a male infant with a left upper extremity constriction band and CPNH who presented in a delayed fashion. He underwent constriction band release with z-plasty and full decompression of the median, radial, and ulnar nerves at 9 months of age. We also conducted a literature review of CPNH associated with CBS. RESULTS: In Case 1, the patient initially demonstrated minimal motor activity other than active wrist extension suggesting severe ulnar and median motor palsies. Post-operatively, he developed progressive clawing of the fingers, and by 6 months post-operatively he was able to actively flex the fingers with a strong grip and resolution of clawing demonstrating complete median and ulnar motor recovery with no residual deficits. In Case 2, the patient initially presented with severe radial nerve palsy and moderate median and ulnar motor dysfunction. Post-operatively he demonstrated limited ulnar recovery with weak wrist and finger flexion but failed to recover active wrist or finger extension. He thus underwent free functional muscle transfer 8 months post-operatively for wrist extension. Case reports of CPNH associated with CBS suggest that constriction band release and nerve decompression at 3 months of age or later fail to provide regain of motor function, but earlier intervention may result in variable motor recovery. CONCLUSIONS: Our experience with early versus delayed constriction band release in children with associated CPNH supports the principle of early intervention for maximal functional recovery. We recommend early diagnosis of upper extremity CBS, in utero if possible, followed by prompt evaluation by a pediatric hand surgeon at the time of birth. If there is suspicion for CPNH at birth, urgent excisional constriction band release and nerve decompression should be performed. Early recognition and intervention, including within the first few hours of life, provides the best chance of full functional recovery. REFERENCES 1. Uchida Y, Sugioka Y. Peripheral nerve palsy associated with congenital constriction band syndrome. J Hand Surg Br. 1991;16(1):109-12. 2. Rapp SJ, Pan BS, Yakuboff KP. Flail extremity resulting from constriction band syndrome: Neurovascular implications and surgical management. Case Reports Plast Surg Hand Surg. 2004; 1(1):29-32. 3. Mohan AS, Russo SA, Pet MA. Early Surgical Intervention in Amniotic Band Sequence for Upper Extremity Motor Nerve Palsies: A Case Report. Hand. 2022;17(1):NP5-NP11. 4. Weeks PM. Radial, median, and ulnar nerve dysfunction associated with a congenital constricting band of the arm. Plast Reconstr Surg. 1982;69(2):333-6. 5. Weinzweig N, Barr A. Radial, Ulnar, and Median Nerve Palsies Caused by a Congenital Constriction Band of the Arm: Single-Stage Correction. Plast Reconstr Surg. 1994;94(6):872-6.

Background: Hand infections make up a significant proportion of patients evaluated by the hand surgeon in the emergency department. There are multiple comorbidities that increase a patient's risk of developing a hand infection including diabetes mellitus, immunosuppression, and intravenous drug use. Despite this, there is a paucity of literature on the impact comorbid psychiatric diagnoses have on the rates of patient presentation to the emergency department for management of a hand infection. The goal of this study was to evaluate rates of patient presentation for hand infection in the presence of a comorbid psychiatric diagnosis and compare this to the general population.

Methods: We performed a retrospective case control study based on data from Cosmos, a nationwide Epic® electronic health record database. All emergency room encounters related to hand infections over a three-year period from 2020-2023 were evaluated for the presence of a comorbid psychiatric diagnosis within the patient's problem list. The rates of hand infection between the control population were then compared to rates in patients with a documented psychiatric diagnosis. Statistical analysis was performed using GraphPad Prism version 10.0.0 with a significant p-value set at 0.05 and 95% confidence intervals for odds ratios calculated using the Woolf logit method.

Results: Data analysis included 94,210,226 unique encounters representing 42,786,312 individual patients. The rate of presentation for hand infection in patients with a concomitant psychiatric diagnosis was significantly higher than in patients without history of a psychiatric disorder (0.06% versus 0.01%, p<0.0001). When evaluating subgroups of psychiatric diseases based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, the rate of presentation for hand infection remained significantly higher for patients with schizophrenia and psychotic disorders (0.06% versus 0.01%, p<0.0001), bipolar disorder (0.8% versus 0.01%, p<0.0001), depressive disorders (0.05% versus 0.01%, p<0.0001), anxiety disorders (0.05% versus 0.01%, p<0.0001), and trauma and stressor related disorders (0.05% versus 0.01%, p<0.0001).

Conclusions: The rate of presentation for hand infections to the emergency department in this study was significantly higher in patients with a comorbid psychiatric diagnosis. An understanding of risk factors for the development of hand infections can help guide the practitioner in appropriate assessment and management of this complex problem.

Background: The incidence of Breast Cancer Related Lymphedema ranges from 15-40 % after a complete axillary lymph node dissection (ALND) depending on other treatment modalities like chemotherapy, radiation, and the extent of dissection (1). The Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) reduces the risk of lymphedema after ALND (2). We identified surgical factors of LYMPHA that influence lymphedema rates focusing on the lymphatic vessel caliber utilized.

Methods: A single-institution retrospective cohort study included breast cancer patients undergoing ALND and LYMPHA from April 2021 to November 2022 with a follow-up of at least one year. Lymphedema was defined as a Lymphedema Index (L-Dex) (Bioimpedance Spectroscopy) measurement outside the normal range (±10 L-Dex unit) or an increase of ≥10 units from baseline. The primary outcome was the correlation between the L-Dex of patients with a lymphatic caliber of ≤0.6 mm vs >0.6 mm. The secondary outcome was to assess the difference in the L-dex from baseline after a follow-up of one year.

Results: 58 patients with documented lymphatic caliber were analyzed. The mean age and BMI were 52.1 years [SD 11.2] and 27.2 [SD 5]kg/m2 respectively. We divided them into two cohorts: patients that had lymphatic caliber ≤0.6 mm 55.2 %(n=32) vs >0.6 mm 44.8%(n=26). The demographic characteristics and cancer stage were equally distributed between both cohorts. Treatment factors like receipt of taxane-based chemotherapy, radiation, number of nodes resected, number of positive nodes, and number of anastomoses that influence lymphedema rates were equally distributed between both cohorts. The median baseline L-Dex in patients with a lymphatic caliber ≤0.6 mm was 2.25 [2.85] and 2.80 [2.69] for lymphatic caliber > 0.6 mm (p=0.76). After one-year follow-up, the L-Dex was 4.20 [7.74] for lymphatic caliber ≤0.6 mm and 1.80 [2.42] for lymphatic caliber >0.6 mm (p=0.006). The L-Dex difference from baseline was higher for lymphatic caliber ≤ 0.6 mm compared to >0.6 mm (3.15 vs 2.65, p=0.02). 6 patients (10%) developed lymphedema, all of whom had a lymphatic caliber ≤0.6 mm. A larger lymphatic caliber was associated with a lower L-Dex at 12 months (p=0.01). It was also associated with a lesser difference from the baseline after one year which was maintained on univariate analysis (p=0.02) and multivariate analysis controlling for radiation, chemotherapy, and number of lymph nodes excised (p=0.04).

Conclusion: Lymphatic vessel caliber >0.6 mm during LYMPHA with ALND is associated with a lower postoperative L-Dex and less increase from the baseline L-dex score. The present analysis highlights an opportunity for collaboration in a multi-institutional study to improve the standardization of LYMPHA.

References 1. DiSipio, T. et al. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 14, 500–515 (2013). 2. Levy, A. S. et al. Lymphatic Microsurgical Preventive Healing Approach for the Primary Prevention of Lymphedema: A 4-Year Follow-Up. Plast. Reconstr. Surg. 151, 413 (2023).

Background Despite advancements in traumatic brachial plexus injury (BPI) management, reconstructive surgical techniques are not feasible for all patients, leading to amputation. Recently, myoelectric prosthetic capabilities have greatly enhanced terminal prosthetic grasp and release, leading to improved skillfulness of prosthetic use. The aim of this study was to evaluate the function and activity performance of prosthetic fitting with myoelectric controls for upper extremity amputees after BPI.

Methods A retrospective analysis of adult patients with amputation after BPI at a single clinic was performed. Patients that underwent myoelectric prosthesis (MEP) fitting after amputation were included. Demographics, mechanisms of injury, amputation characteristics and outcomes were collected from medical records. The Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, to evaluate the impact of impairment, Visual Analog Scale (VAS) to evaluate pain, and the Activities Measure for Upper Limb Amputees (AMULA) to evaluate activity performance were collected. Prosthesis usage, satisfaction and signal transducers were also recorded. Paired t-tests were used to compare outcomes.

Results Sixty patients with BPI between were identified. Of these, 13 patients (90% male, average age of 34 years at time of BPI) were fitted with MEPs with electromyographic signal control from muscles not normally associated with the intended function (nonintuitive control) after elective amputation. Among these, 10 patients underwent trans-radial amputation and 3 patients underwent trans-humeral amputations. Amputations occurred to the dominant limb in 3 out of 13 patients. Reasoning for amputation included lack of function or desiring more function. Disability (DASH) did not significantly differ, with average scores of 53 pre-amputation compared to 51 post-amputation (DASH score, p=0.17). Average pain score were also not significantly different post-amputation (6.6 versus 4.4, mean difference 2.2, p=0.054). Linear transducers were used in 60% to fit MEPs and in 40%, traditional electrodes were used. AMULA scores denoted a significant improvement in activity performance after use of prosthesis (p=0.0005). All patients demonstrated functional terminal grasp and release with an average use of 6 hours per day. Hundred percent of patients found their fitted MEP useful during daily activities and were satisfied after an average of 4 months follow-up.

Conclusions Elective upper extremity amputations following BPI did not decrease pain and disability significantly. However, validated AMULA scores found that activity performance using MEPs improved significantly. Patients used their prosthetics around 6 hours per day with a hundred percent satisfaction rate and functional terminal grasp and release.

PURPOSE: Although the safety and efficacy of vascularized lymph node transplant (VLNT) have been confirmed up to two years post-surgery, there is limited published data regarding outcomes beyond this timeframe. This prospective study aimed to assess postoperative outcomes at the three-year mark utilizing both objective and subjective metrics. METHODS: All patients underwent VLNT at a tertiary cancer center between November 2014 and January 2023. Outcomes were assessed using 2 validated patient-reported outcome metrics (PROMs), limb volume, bioimpedance, need for compression, and incidence of cellulitis. RESULTS: A total of 110 patients were included with the following donor sites: omentum (80.0%), axilla (9%), supraclavicular (5%) and groin (2.5%). The mean follow-up time was 32.5±11.2 months. A significant improvement across all outcome measures was recorded at 36 months postoperatively: 30.7% average reduction in limb volume (p=0.02), 44.1% improvement (p=0.01) in bioimpedance (LDEX) scores (p=0.001), 36.7% improvement in the Lymphedema Life Impact Scale scores (p=0.03) and 97% reduction in cellulitis (p=0.001). 46% of patients no longer required compression. No cases of donor site lymphedema were recorded (0%). CONCLUSION: Vascularized lymph node transplant (VLNT) results in sustained enhancements in both overall limb volume and quality of life, extending beyond the initial two years post-surgery and up to 36 months postoperatively.

ABSTRACT The incidence of hand injuries in our country amounts to up to 160,250 per year. Of all of them, tendon injuries, whether flexor tendons (TF) or extensor tendons (ET), represent up to 30% of all consultations referred to the emergency department (1,2). Depending on the characteristics of the injury, treatments can be performed. either with autologous grafts (taken from the same individual) or allogeneic grafts (obtained from a cadaveric donor) (3,4)

The purpose of this study is to know if there is a functional difference between reconstruction using autologous grafts compared to reconstruction with allogeneic grafts for tendon injuries of the hand.

A search was carried out for patients with a history of tendon injuries of the hand treated by the plastic and reconstructive surgery service of the CMI Toluca in a period between January 2015 to March 2023. Questionnaires such as the QDash-Score were carried out for the functional evaluation of the injured hand as well as Likert-type satisfaction surveys and objective tests using a dynamometer and goniometer to evaluate strength and the resulting ranges of mobility.

The sample consisted of 10 male patients (76.9%) and 3 female patients (23.1%). The median age was 40 years (IQR 35, 57), with a range of 21 to 61 years. The most affected finger was the fourth finger, in 6 patients (46.2%), followed by the second finger in 3 patients (23.1%) and the third finger in 2 patients (14.4%). Both the first finger and the fifth finger were injured in only one patient (7.7%), an autologous graft was used in 5 patients (38.5%) and an allogeneic graft was used in 8 patients (61.8%). Patients with an allogeneic graft presented a significantly smaller decrease in the flexor angle of the distal interphalangeal joint than patients with an autologous graft (p=0.02), with a difference between healthy hand and injured hand of 11.0° (SD 15.3) and 39.8° (SD 12.7), respectively (difference 28.8°, 95% CI 10, 47). The other functional characteristics did not show significant differences. However, patients with allogeneic graft showed a smaller difference between healthy and injured hand in the proximal interphalangeal flexor angle (p=0.09).

Among the conclusions drawn in this study, a clear trend is observed towards a better result in the objective tests of mobility ranges and coarse and fine grip strength for hands reconstructed with allogeneic grafts, as well as in subjective tests such as the Q-Dash score and the Likert questionnaire in which the percentage of disability was slightly lower for the allogeneic graft group and the percentage of satisfaction was higher respectively. It is worth remembering the importance of the timely recognition of tendon injuries of the hand, as well as the adequate identification of the injured structures, which are of vital importance for the plastic and reconstructive surgeon to reestablish the function or functions lost secondary to tendon disruptions, vascular or nerve injuries of the hand.

Background: Health disparities are multifactorial and remain a national and international public health problem with a significant financial burden. To this end, this study aimed to evaluate how racial/ethnic backgrounds and social determinants contribute to healthcare disparities in patients with carpal tunnel syndrome (CTS), including the time to and rates of surgical treatment.

Methods: A national insurance-based database (Pearldiver inc.) was utilized for this retrospective study of 308,662 patients with CTS. Patients with ICD-9 and ICD-10 codes corresponding to "hand pain" and a diagnosis of CTS between 2014-and 2016 were identified using corresponding ICD-9 and ICD-10 codes. Subsequent carpal tunnel release was identified using it's corresponding CPT codes and time from diagnosis to treatment was compared among racial groups.

Results: Black and Hispanic patients were found to have significantly prolonged time to diagnosis and time to treatment of their CTS compared to White Patients. Patients of any racial or ethnic minority were 52-59% less likely to undergo CTR compared to White patients. Having any reported SDOH decreased the odds of undergoing CTR by 46%. In addition, males and people from the South and Midwest were more likely to undergo surgical release compared to females and patients from the Northeast.

Conclusion: Racial and social disparities are present when diagnosing and treating carpal tunnel syndrome predisposing patients to delays in operative intervention. It is important to build increased recognition of these issues in the medical community and put forth tangible goals to work toward equity in operative intervention.

Introduction: Fingertip injuries are common among children, peaking in incidence at two years of age. A paucity of data exists in the literature regarding recovery and patient-reported outcomes (PROs) following these frequent injuries. This study aims to evaluate PROs regarding upper extremity function and fine motor skills following treatment of pediatric fingertip injuries.

Methods: Institutional Review Board approval was obtained. Children evaluated for fingertip injuries in the emergency department and clinic between July 2018 and March 2023 at a Level 1 children's hospital in a large metropolitan city in the United States were identified. Inclusion criteria included age at injury <18 years. Demographics were collected. Pediatric Upper Extremity – Short Form 8a and Pediatric Upper Extremity Function – Fine Motor, ADL forms were administered to included patients with available contact information. The PROMIS scoring guide was used to determine statistically significant differences from age-matched controls. PROMIS scores were compared to national age-matched control averages using Student's t-test.

Results: 184 patients were identified for inclusion – of these, 92 patients had verifiable contact information. 49.5% of patients were male, 50.5% female. Mean age of patients was 4.73 years (range <1-16 years). Injuries were most commonly due to crush injuries inside doors (48.4%) and predominantly affected the third/fourth digits of each hand (p=0.028). Most patients (61.4%) treated in the emergency department underwent repair. Repairs included bedside soft tissue only (43.8%), bedside soft tissue and nailbed (48.2%), and operating room intervention (8.0%). 22/92 (24%) parents/guardians completed both surveys. Average follow-up time from injury to survey completion was 584 days (~1.6 years). 8/184 (8.0%) of patients underwent additional procedures later. For all injury and repair types, children treated for fingertip injuries showed no significant difference in reported upper extremity function (p=0.345) or fine motor skills (p=0.458) compared to national averages using PROMIS surveys.

Conclusions:
Children treated for fingertip injuries at our institution reported favorable PROs. There is no long-term difference in fine motor or upper extremity function PROs for children treated for fingertip injuries compared to age-matched controls. Future directions could include evaluation of psychological impact of the injured finger aesthetic and need for additional procedures based on injury patterns.

Background: Triangular fibrocartilage complex (TFCC) injuries can be a significant source of dysfunction in patients [1]. Platelet-rich plasma (PRP) has gained attention as an adjunctive treatment in patients who receive arthroscopic repair of TFCC injury, with studies suggesting that PRP may improve patient outcomes [2]. The current study aims to evaluate and compare the use of PRP as an adjunctive treatment in patients undergoing arthroscopic repair of TFCC tears. Methodology: This retrospective study reviewed patients who had arthroscopic TFCC repair between 2021-2022. Physical exams were conducted pre and post-treatment, recording flexion, extension, radial/ulnar deviation of affected and contralateral wrists. Pre- and post-operative VAS pain scores and Quick DASH function scores were compared to assess improvements. Results: A total of 33 patients (20 male, 13 female) with a mean age of 30.55 ± 9.17 years were included. 16 received PRP injections adjunct to arthroscopic TFCC repair, while 17 had repair alone. No significant differences existed preoperatively between groups in wrist function or pain (p>0.05). The mean postoperative follow-up was 3.94 ± 1.66 months. The PRP group showed greater improvement in Quick DASH scores (mean change 7.75 ± 5.91) compared to the non-PRP group. No significant difference was seen in pain VAS between groups. Conclusion: The use of PRP as an adjuvant for TFCC injuries after arthroscopic repair remains debated. In our study, patients receiving PRP after arthroscopic repair of peripheral TFCC tears showed significant improvement in Quick DASH scores. Further prospective studies are needed to confirm these findings. References: 1. Jawed A, Ansari MT, Gupta V. TFCC injuries: How we treat? J Clin Orthop Trauma. 2020;11(4):570–579. doi:10.1016/j.jcot.2020.06.001 2. Kon E, Gobbi A, Filardo G, et al. Arthroscopic Second-Generation Autologous Chondrocyte Implantation Compared with Microfracture for Chondral Lesions of the Knee. Am J Sports Med. 2009;37(1):33–41. doi:10.1177/0363546508323256

Animal bites and stings have become a regular feature of Plastic Surgery trauma lists in Australia. Although they rarely require reconstruction, these bites and stings often affect the hands and/or require the attention of a soft tissue surgical specialist. Despite the association of snakes, spiders and crocodiles with Australia, most of these injuries are from domesticated cats and dogs. In this paper, however, we consider more atypical (and perhaps novel) culprits in the form of Australian native wildlife. The first case we present is of a platypus sting to the palm of a middle-aged woman. With its duck-like bill, beaver-like tail and reptilian-like egg laying, the platypus is one of Australia's more peculiar mammals. Few Australian – let alone American - practitioners would be sufficiently familiar with the platypus' mammology to know that this animal even has a venomous spur, which is located on the underside of the rear legs of the male platypus. The venom, which is produced in greater quantities during mating season, is not cytotoxic to humans but does cause profound pain and swelling. At the time of writing, only a single case report has been published in respect of a platypus sting (Tonkin & Nardine, 1994). That report, describes the patient as requiring a 6-day admission for pain refractory to opioid analgesia after a platypus sting. We present a case of a platypus sting to the zone III palm which, due to its depth and location, required operative exploration and washout, with the patient being discharged the following day and on opioid-free simple analgesia at one week post-admission. Although platypus stings are exceedingly rare and the limitations of drawing conclusions from isolated cases, our patient had a significantly better outcome than the published experience. From freshwater to land, the second case we present is of an elderly woman being mauled in her own bed by a wombat. The wombat is a quadrupedal, furry and rotund herbivore with long claws on its front paws for digging burrows. Wombats are typically reclusive and timid, and there are no published reports of attacks against humans. In this case, the patient was sleeping in their own bed, with doors open for airflow in the Australian summer, when they were mauled on the lower limbs. The patient sustained numerous subfascial wounds requiring surgical washout and debridement by the Plastic Surgery team. Together, these cases provide insight to the rare and interesting Plastic Surgery admissions and operative intervention in attacks by usually docile and reclusive native Australian animals.

M.A. Tonkin, J. Negrine, Wild platypus attack in the Antipodes A case report, The Journal of Hand Surgery: British & European Volume, Volume 19, Issue 2, 1994, Pages 162-164, ISSN 0266-7681, https://doi.org/10.1016/0266-7681(94)90155-4.

Purpose/background: Ganglion cysts are non-cancerous growth of the hand and wrist commonly found in the pediatric population, affecting as much as 10% of patients under the age of 20 (1). Previous studies have identified that pediatric cysts may present with unique epidemiological characteristics and require different treatment algorithms than adult cysts (2). However, many of these studies were limited by small sample sizes and may not be representative. The present study utilized a national administrative claims database to investigate the age-related incidence of pediatric ganglion cysts and predictors of pursuing surgical excision.

Methods: Patients who were diagnosed with a hand or wrist ganglion cyst were identified from the PearlDiver Mariner161 insurance claims database. Exclusion criteria were ganglion cyst diagnoses in more than one location, an insurance type that was not commercial or Medicaid, missing characteristics such as sex or region, age older than 18, and records active for fewer than 2 years. Ganglion cyst treatments such as bracing, aspiration/injection, surgery, and revision surgery were identified in addition to the use of diagnostic imaging. Patients diagnosed with a ganglion cyst and the proportion that underwent surgery were stratified by age at the initial recorded diagnosis. Non-linear exponential fit and simple linear regression were used to analyze these trends respectively. The likelihood of proceeding to surgical excision and revision surgery was analyzed using univariate and multivariate analysis. Time to surgical excision for different cyst locations was analyzed using a log-rank test.

Results: Approximately 37,021 pediatric patients with a ganglion cyst located on the hand or wrist were identified. The number of patients that were diagnosed at each age increased exponentially (R-squared: 0.9494), while the proportion of patients diagnosed at each age that underwent surgical excision increased linearly (R-squared: 0.9699). Increased age (OR: 1.07, 95% CI: [1.06, 1.08], p<0.0001), female sex (OR: 1.37, 95% CI: [1.26, 148], p<0.0001), and utilization of x-ray for diagnosis (OR: 1.77, 95% CI: [0.98, 1.69], p<0.0001) were associated with greater likelihood of pursuing surgery while cyst location on the hand (OR: 0.54, 95% CI: 0.49, 0.60], p<0.0001) was predictive of not receiving surgery compared to wrist-located cysts. Differences in 2-year time to surgical excision for patients with hand- or wrist-located ganglion cysts were statistically significant as determined by Kaplan-Meier survivorship analysis, with wrist-location cyst receiving operation at a greater rate initially and more overall (p<0.0001). Among patient demographic and treatment characteristics, female sex was predictive of an increased likelihood of receiving a surgical revision (OR: 1.57, 95% CI: [1.04, 2.44], p=0.0368), and all cases of recurrence involved wrist-located cysts.

Conclusions: The current study presents a nationwide analysis of ganglion cyst prevalence and treatment characteristics in the pediatric population. The proportion of patients undergoing surgery for ganglion cysts increased linearly with age, demonstrating that there is no specific cutoff where the treatment algorithm changes. Moreover, specific predictors for receiving surgery and recurrence after surgery were identified. These are important to consider during patient counseling and surgical planning respectively.

References 1. Nelson CL, Sawmiller S, Phalen GS: Ganglions of the wrist and hand. J Bone Joint Surg Am 1972;54:1459-1464. 2. Satku K, Ganesh B: Ganglia in children. J Pediatr Orthop 1985;5:13-15.