BACKGROUND:The COVID-19 pandemic and duty hour restrictions illuminated a role for surgical simulation in hand surgery training that permits meaningful technical experience outside the operating room. Implementation of surgical simulation infrastructure alongside clinical training accounting for complexity and cost should be considered. This systematic review analyzes cadaveric, benchtop, 3D-printed, augmented/virtual reality, and animal models that may effectively simulate hand surgical techniques and procedures with subjective or objective competence assessment. METHODS:A systematic review was conducted according to PRISMA-P guidelines using the following databases: PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane. Selected search terms included procedures relevant to hand surgery and various simulation training modalities. Inclusion criteria were English-language peer-reviewed articles about surgical simulation techniques or hand surgery-related training. Abstracts, conference proceedings, non-English literature, and reviews were excluded. Data, including skills and techniques taught and assessed, model type, equipment, cost, and emphasis placed in training for each article, were entered into an electronic database. Additional articles were identified through references from the initial search. RESULTS:Our search criteria identified 2745 articles, 39 of which met the inclusion criteria. Models were described with the following frequency: synthetic benchtop/3D printed (41.0%), animal (25.6%), cadaveric (17.9%), augmented and virtual reality (AR/VR; 10.3%), and other computer simulation (10.3%). Three models incorporated both a physical benchtop and AR/VR components. The procedures most represented by the simulation tools assessed include tendon repair (30.8%), fracture fixation (25.6%), wrist arthroscopy (15.4%), and carpal tunnel release (15.4%). Of all articles, 51.3% evaluated the efficacy of the educational tool. Of these, 40.0% were evaluated via subjective methods only, 10.0% via objective methods, and 50% via both. Eighty-seven percent of articles emphasized the importance of surgical simulation in a surgeon's training. CONCLUSIONS:A diverse collection of hand surgical simulation models exists for the practice of various aspects of hand surgery. The existing literature demonstrates their utility for increasing expertise with surgical techniques and procedures in a low-risk setting. Integration into surgical training will depend on program time and budget constraints.

BACKGROUND:Limb length preservation is correlated with overall survival. Successful free flap coverage of forefoot, midfoot, and hindfoot amputations can prevent more proximal below-knee amputations but is challenging in patients with multiple comorbidities. The thin superficial circumflex iliac artery perforator (SCIP) flap is well-suited for these patients, as it provides thin, pliable tissue from a favorable donor site. METHODS:A retrospective review of all patients with distal amputations requiring coverage with a thin SCIP flap between 2016 to 2022 was performed. Patient demographics, amputation levels, and wound characteristics in addition to flap and microsurgery details were analyzed. The primary outcome was limb salvage. Secondary outcomes included partial flap necrosis, flap revision rate, and additional postoperative complications. RESULTS:Thirty-two patients (mean age, 57.3 years) underwent reconstruction of forefoot, midfoot, and hindfoot amputations with thin SCIP flaps (mean follow-up, 36 months). Twenty-eight patients (87.5%) had diabetes, 27 (84.4%) had peripheral artery disease, and 15 (46.9%) were dialysis-dependent. Average flap size was 59.5 cm 2 and average flap thickness was 5.7 mm. Successful limb salvage was achieved in 27 patients (84.3%). Three cases (9.4%) had total flap loss. Twenty-one flaps (65.6%) had partial necrosis, of which 12 (57.1%) healed with conservative management and 7 (33.3 %) healed after late revision. CONCLUSIONS:The thin SCIP flap is a useful option for coverage of distal pedal amputations in patients with significant comorbidities. Despite higher rates of partial flap necrosis, free flap reconstruction allowed for high rates of limb salvage in a challenging patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

This case series describes the clinical course and reconstructive methods utilized for patients with diabetes and significant gangrene and necrosis following coronavirus disease 2019 (COVID-19) infection. COVID-19 produces mainly respiratory symptoms but has a variety of atypical presentations and sequelae. Serious complications are increased in patients with underlying medical conditions such as diabetes mellitus. By generating a prothrombotic milieu, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) increases the risk for arterial and venous thromboses. Inflammatory damage and micro-thromboses are thought to contribute to acro-ischemia, colloquially known as 'COVID toes,' which presents cutaneously as chilblain-like lesions. Necrosis can be severe and devastating, often resulting in major amputation. Two exemplary case reports are presented herein: first, a 57-year-old female presented for vascular evaluation with pedal gangrene to the midfoot one month after developing painful discoloration in her right toe. After angioplasty restored pedal blood flow, she received a transmetatarsal amputation (TMA) with a local tissue flap. Second, a 41-year-old female presented for vascular evaluation with extensive pedal gangrene three months after hospitalization for COVID-19. After arteriotomy improved pedal blood flow, she underwent a Lisfranc amputation followed by superficial circumflex iliac artery perforator (SCIP) flap reconstruction. Sufficient evidence suggests that COVID-19 impairs microcirculatory function and can be especially detrimental in diabetic patients. Reconstructive techniques in patients with severe gangrene with COVID toes help patients regain functionality.

Leprosy is a chronic infection of the skin, eyes, and peripheral nerves due to the slow-growing, acid-fast bacillus Mycobacterium leprae. Devastating complications include Charcot neuroarthropathy and insensate hands and feet. We present the case of an 81-year-old female with rheumatoid arthritis and 50 years of polar lepromatous leprosy who suffered from bilateral collapsed arches, flat feet, and bone deformities of Charcot feet.

Background:Lymphatic dyes are commonly used to map the drainage path from tumor to lymphatics, which are biopsied to determine if spread has occurred. A blue dye in combination with technetium-99 is considered the gold standard for mapping, although many other dyes and dye combinations are used. Not all of these substances have the same detection efficacy.Methods:A systematic review of PubMed, SCOPUS, Web of Science, and Medline was performed. The predefined search terms were (indocyanine green OR isosulfan blue OR lymphazurin OR patent blue OR methylene blue OR fluorescein OR technetium-99) AND combination AND dye AND (sentinel lymph node biopsy OR lymphedema OR lymphatics OR lymph OR microsurgery OR cancer OR tumor OR melanoma OR carcinoma OR sarcoma).Results:The initial search returned 4267 articles. From these studies, 37 were selected as candidates that met inclusion criteria. After a full-text review, 34 studies were selected for inclusion. Eighty-nine methods of sentinel lymph node (SLN) detection were trialed using 22 unique dyes, dye combinations, or other tracers. In total, 12,157 SLNs of 12,801 SLNs were identified. Dye accuracy ranged from 100% to 69.8% detection. Five dye combinations had 100% accuracy. Dye combinations were more accurate than single dyes.Conclusions:Combining lymphatic dyes improves SLN detection results. Replacing technetium-99 with ICG may allow for increased access to SLN procedures with comparable results. The ideal SLN tracer is a low-cost molecule with a high affinity for lymphatic vessels due to size and chemical composition, visualization without specialized equipment, and no adverse effects.

Introduction: The COVID-19 pandemic and duty hour restrictions have illuminated a role for surgical simulation in trainees that permits meaningful technical experience outside the operating room. There is a need for the implementation of surgical simulation infrastructure adjacent to clinical training with practical considerations for complexity and cost. This systematic review analyzes surgical simulations that train hand surgical techniques and procedures with subjective or objective competency assessment. Method(s): A systematic review was conducted according to PRISMA- P guidelines using the PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane databases. Selected search terms included procedures relevant to the field of hand surgery and various types of simulation training. Data, including skills and techniques taught and assessed, model type, equipment, cost, and emphasis placed in training for each article, were extracted. Result(s): Of 2,519 articles, 40 met inclusion criteria. Models were described as: synthetic benchtop/3D-printed (40.0%), animal (22.5%), cadaveric (20.0%), augmented and virtual reality (AR/ VR;12.5%), and other computer simulation (12.5%). Three models incorporated both a physical benchtop component and an AR/ VR component. The procedures most represented included tendon repair (30.0%), fracture fixation (27.5%), wrist arthroscopy (15.0%), and carpal tunnel release (15.0%). Sixty-five percent of articles emphasized the importance of surgical simulation in a surgeon's training. Conclusion(s): A diversity of surgical simulation models exist for the practice of various aspects of hand surgery. The existing literature demonstrates their utility for increasing expertise with surgical techniques and procedures in a low-risk setting.

Artificial intelligence can use real-world data to create models capable of making predictions and medical diagnosis for diabetes and its complications. The aim of this commentary article is to provide a general perspective and present recent advances on how artificial intelligence can be applied to improve the prediction and diagnosis of six significant complications of diabetes including (1) gestational diabetes, (2) hypoglycemia in the hospital, (3) diabetic retinopathy, (4) diabetic foot ulcers, (5) diabetic peripheral neuropathy, and (6) diabetic nephropathy.

OBJECTIVE Evaluate the inter- and intra-rater reliability of a wound assessment tool in iPhone 12 and 13 mini modalities against a validated iPad mini/Structure Sensor configuration. APPROACH We assessed a wound measurement application (eKare inSight) for result consistency in patients presenting with wounds. Assessments were analyzed using a two-way analysis of variance (ANOVA). Intraclass Correlation Coefficient (ICC) was computed for intra-rater (ICC1,1) and inter-rater (ICC2,1) analysis using a two-way random effects model. Paired t-test assessed the statistical difference between measurement methods. RESULTS Forty-two lesions were analyzed with surface areas ranging from 0.2 cm2 to 23 cm2 (average 4.33 ± 5.44 cm2). A high level of reliability was observed for repeat wound area measurements by the same examiner (ICC1,1 = 0.997) and between examiners with iPhone 13 mini (ICC2,1 = 0.998). There was no significant difference between iPhone 12 and iPad mini/Structure Sensor (p=0.78) or between iPhone 13 mini and iPhone 12 (p=0.22). Minimal difference existed between iPhone 13 mini and iPad mini/Structure Sensor (p=0.049, Cohen's d=0.01). INNOVATION Increased pervasiveness of smartphones in clinical care, coupled with advances in smartphone imaging and machine learning, allows for a potential solution to the problem of fast and accurate wound measurements. The application investigated produces wound measurement results quickly and with demonstrated accuracy. It does not require a calibration sticker or reference marker and allows for automatic wound boundary delineation. CONCLUSION The results of this study suggest that a digital planimetry mobile application may offer high levels of reliability across devices and users.

Background:Pressure injuries (PIs) impose a substantial burden on patients, caregivers, and healthcare systems, affecting an estimated 3 million Americans and costing nearly $18 billion annually. Accurate pressure injury staging remains clinically challenging. Over the last decade, object detection and semantic segmentation have evolved quickly with new methods invented and new application areas emerging. Simultaneous object detection and segmentation paved the way to segment and classify anatomical structures. In this study, we utilize the Mask-R-CNN algorithm for segmentation and classification of stage 1-4 pressure injuries.Methods:Images from the eKare Inc. pressure injury wound data repository were segmented and classified manually by two study authors with medical training. The Mask-R-CNN model was implemented using the Keras deep learning and TensorFlow libraries with Python. We split 969 pressure injury images into training (87.5%) and validation (12.5%) subsets for Mask-R-CNN training.Results:We included 121 random pressure injury images in our test set. The Mask-R-CNN model showed overall classification accuracy of 92.6%, and the segmentation demonstrated 93.0% accuracy. Our F1 scores for stages 1-4 were 0.842, 0.947, 0.907, and 0.944, respectively. Our Dice coefficients for stages 1-4 were 0.92, 0.85, 0.93, and 0.91, respectively.Conclusions:Our Mask-R-CNN model provides levels of accuracy considerably greater than the average healthcare professional who works with pressure injury patients. This tool can be easily incorporated into the clinician's workflow to aid in the hospital setting.

Background: Diabetic foot ulcers (DFUs) are a leading cause of disability and morbidity. There is an unmet need for a simple, practical, home method to detect DFUs early and remotely monitor their healing. Method: We developed a simple, inexpensive, smartphone-based, “ Foot Selfie” system that enables patients to photograph the plantar surface of their feet without assistance and transmit images to a remote server. In a pilot study, patients from a limb-salvage clinic were asked to image their feet daily for six months and to evaluate the system by questionnaire at five time points. Transmitted results were reviewed weekly. Results: Fifteen patients (10 male) used the system after approximately 5 minutes of instruction. Participants uploaded images on a median of 76% of eligible study days. The system captured and transmitted diagnostic quality images of the entire plantar surface of both feet, permitting clinical-management decisions on a remote basis. We monitored 12 active wounds and 39 pre-ulcerative lesions (five wounds and 13 pre-ulcerative lesions at study outset); we observed healing of seven wounds and reversal of 20 pre-ulcerative lesions. Participants rated the system as useful, empowering, and preferable to their previous methods of foot screening. Conclusions: With minimal training, patients transmitted diagnostic-quality images from home on most days, allowing clinicians to review serial images. This system permits inexpensive home foot screening and monitoring of DFUs. Further studies are needed to determine whether it can reduce morbidity of DFUs and/or the associated cost of care. Artificial intelligence integration could improve scalability.

SUMMARY:Volume replacement in oncoplastic breast reconstruction most commonly uses pedicled flaps. In thin patients with small breasts, free-tissue transfer may be better suited to preserve breast size. Evidence on microvascular oncoplastic reconstruction is limited, and reconstruction has often required sacrifice of potential future donor sites. The free superficially based low-abdominal mini (SLAM) flap uses a narrow strip of lower abdominal tissue based on superficial perfusion of the abdominal wall that is anastomosed to chest wall perforators to preserve the ability to perform future abdominally based autologous breast reconstruction. Five patients underwent reconstruction with SLAM flaps for immediate oncoplastic reconstruction. Their mean age was 49.8 years, and their mean body mass index was 23.5. Tumor location was most commonly in the lower outer quadrant (40%). Average lumpectomy weight was 30 g. Two flaps were based on the superficial inferior epigastric artery, and three, on the superficial circumflex iliac artery. Recipient vessels included internal mammary perforators (40%), serratus branch (20%), lateral thoracic vessel branch (20%), and lateral intercostal perforators (20%). All patients underwent radiation therapy without delay and maintained volume, symmetry, and contour at an average period of 11.7 months after surgery. There were no cases of flap loss, fat necrosis, or delayed wound healing. The free SLAM flap allows for immediate oncoplastic breast reconstruction in thin, small-breasted patients with limited regional tissue without sacrificing future potential donor sites for autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.

BackgroundThe Plastic Surgery Common Application (PSCA) has emerged as a low-cost alternative application portal to the Electronic Residency Application Service (ERAS) for integrated plastic surgery applicants. During the 2021 to 2022 application cycle, our plastic surgery residency program accepted both the PSCA and ERAS applications to help recruit candidates otherwise deterred by prohibitively high application costs. We sought to determine how the PSCA compared with the ERAS application in a standardized review of applications scores.MethodsThe PSCA and ERAS applications from 28 candidates who received interviews from the Keck School of Medicine were analyzed. These 56 applications were randomly assigned across 22 independent reviewers. Each reviewer scored applications on a scale of 1 to 5 with regard to communication skills, leadership, intellectual curiosity, compatibility with the program, service, and perseverance. Mean scores between the applications were compared using 2-tailed z tests, with statistical significance set at P < 0.05.ResultsThe 56 residency applications had a combined mean score of 4.21 (95% confidence interval [CI], 4.13-4.29). The mean score of PSCA applications (4.19; 95% CI, 4.08-4.31) did not significantly differ from the mean score of ERAS applications (4.24; 95% CI, 4.12-4.35; P = 0.57). The PSCA and ERAS applications did not have a significant difference in the mean scores for any review category.ConclusionThere was no difference between the overall scores and the scores of each review category between the PSCA and ERAS applications, suggesting that the PSCA may be a reasonable alternative to ERAS for medical students applying to plastic surgery residency.

Background:. Foot deformities and gait abnormalities can result in locally elevated peak pedal pressures or atypical pedal biomechanics. Combined with underlying comorbidities such as neuropathy, stroke, atrophic fat padding and history of ulcerations, this can lead to recurrent ulcerations and pain. Pedal fat grafting (PFG) is a treatment modality that has been shown to reduce peak pressures and accelerate wound healing. This study aimed to investigate the utility of PFG to treat and prevent ulcerations. Methods:. We retrospectively analyzed medical history, demographics, wound volume at time of procedure, volume of fat injected, surgical outcomes, and presence of new wounds in 15 patients who underwent PFG at Keck Hospital between 2018 and 2023. Results:. Seventeen feet from 15 patients (63 ± 12 years old, body mass index 30.9 ± 3.1) received PFG with an average volume of fat injected of 10.7 mL and procedure time of 84.6 minutes. At the time of PFG, nine wounds were present on nine feet with an average wound volume of 1.6 ± 2.7 cm3. Average follow-up was 6.9 months (range 1–36 months), with no complications or recurrent ulcerations since the procedure. Conclusions:. PFG is a promising treatment option for reducing peak pedal pressure and preventing ulcer recurrence in patients with various conditions. Further study is warranted for long-term follow-up.

Background:. Diabetic foot complications are increasingly burdensome for patients, clinicians, and society. Development of innovative therapies to support good quality basic care is a priority among those with an interest in this area. One of these involves scanning and printing tissues to match and conform to a defect (so-called 3D printing). Methods:. A single-arm pilot study of ten consecutive patients with a history of a chronic diabetic foot ulcer (DFU), treated with autologous minimally manipulated homologous adipose tissue (AMHAT), dispensed by a specialized 3D bioprinter, Dr. INVIVO, was performed. Patients with nonhealing DFUs present for more than 4 weeks and refractory to standard-of-care therapies were included. Wounds were treated with a single application of AMHAT, and then followed up weekly for up to 12 weeks, or until the wounds healed. The primary outcome measure was complete epithelialization of the wound up to 12 weeks after the treatment. Secondary outcome measures included wound size and/or volume reduction, assessment of ulcer grade, and time to closure. Results:. Five wounds were healed by 5 weeks and one at 8 weeks. The mean percent area reduction at 12 weeks was 78.3% (SD: 33.23). Complete closure was achieved in 60% of wounds. The mean time to closure in these wounds was 49.1 days (95% CI, 29.9–68.3). No adverse events were reported. Conclusions:. Single treatment of bioprinted AMHAT appears to be a safe and potentially effective treatment modality for patients with chronic DFUs. Further studies are warranted to explore the full potential of 3D bioprinting for tissue repair in this high-risk population.

Objective: Describe the clinical courses of and reconstructive methods utilized for two patients with diabetes who presented with gangrenous feet following Covid-and required partial foot amputations. Background: Covid-produces mainly respiratory symptoms but has a variety of atypical presentations and sequelae. Serious complications are increased in patients with underlying medical conditions such as diabetes mellitus. By generating a prothrombotic milieu, SARS-CoV-2 increases the risk for arterial and venous thromboses. Inflammatory damage and micro-thromboses are thought to contribute to acro-ischemia, colloquially known as “Covid Toes,” which presents cutaneously as chilblain-like lesions. Case Report: (1) A 57 year old female presented to vascular clinic with pedal gangrene one month after developing painful discoloration in her right toes. After angioplasty restored pedal blood flow, she received a TMA with a local fillet flap. (2) A 41 year old female presented to vascular clinic with extensive pedal gangrene three months after hospitalization for Covid-19. After arteriotomy improved pedal blood flow, she underwent a Lisfranc amputation followed by SCIP flap reconstruction. Conclusion: Sufficient evidence suggests that Covid-impairs microcirculatory function and can be especially detrimental in diabetic patients. Reconstructive techniques in patients with severe Covid Toes help patients regain functionality. Disclosure M.Swerdlow: None. G.T.Kress: None. L.Shin: None.

Background Lower extremity reconstruction often requires soft tissue transfer for limb salvage. Flaps are allocated based on injury size, location, and shape coupled with surgeon expertise. Ideally, vascularized tissue should have similar outcomes across local and free tissue transfers. By evaluating outcomes from a Level 1 trauma center, we aim to provide recommendations regarding surgical management of leg reconstruction with respect to local versus free flap implementation. Methods This retrospective review evaluated patient medical history, demographics, flap characteristics, and outcomes from LAC + USC between 2007-2021 using an internal database. Outcomes included failure rates, complications, and ambulation. Results 357 lower extremity flaps were placed on 322 patients; 187 (52.4%) were local and 170 (47.6.%) were free flaps. Twenty-one (11.2%) local flaps suffered significantly more postoperative hardware infections and/or osteomyelitis compared to nine (5.3%) free flaps. Eleven (5.9%) local flaps developed partial necrosis, four requiring revision; 12 (6.4%) total local flaps required revision. Comparatively, sixteen (9.4%) free flaps developed partial necrosis, seven requiring revision; 18 (10.6%) total free flaps required revision. Flap survival was 96.3% for local versus 93.5% for free flaps. Percentage of fully ambulatory patients and time to final ambulation was not significant across cohorts. Discussion Local flaps may portent higher risk for infection; though the cause is not clear, the results may be confounded by comorbidities. Nevertheless, there were no significant differences in flap survival or number of fully ambulatory patients across cohorts. Future studies should evaluate aesthetic results and patient satisfaction across flap types.

Failure to heal a diabetic foot ulcer (DFU) is a leading cause of hospitalization worldwide, amputation, disability, and death among people with diabetes. Unfortunately, even after the resolution of a foot ulcer, recurrence is common and is estimated to be 40% within 1 year. Therefore our efforts should be not only toward rapid healing of open wounds but also maximizing ulcer-free days for the patient in diabetic foot remission. Fortunately, recent exciting developments in digital health have opened an opportunity for creative solutions to prevent this devastating condition and promote ulcer-free days. These technologies could allow care providers to deliver timely and personalized care and empower patient’s central role and responsibility in enabling an optimized health-care ecosystem for better management of DFUs and their recurrence. This chapter overviews the development of digital health, wearables, Internet of Things, and voice-activated command technology for improvement of managing DFUs.

In 2007, we reported a summary of data comparing diabetic foot complications to cancer. The purpose of this brief report was to refresh this with the best available data as they currently exist. Since that time, more reports have emerged both on cancer mortality and mortality associated with diabetic foot ulcer (DFU), Charcot arthropathy, and diabetes-associated lower extremity amputation. We collected data reporting 5-year mortality from studies published following 2007 and calculated a pooled mean. We evaluated data from DFU, Charcot arthropathy and lower extremity amputation. We dichotomized high and low amputation as proximal and distal to the ankle, respectively. This was compared with cancer mortality as reported by the American Cancer Society and the National Cancer Institute. Five year mortality for Charcot, DFU, minor and major amputations were 29.0, 30.5, 46.2 and 56.6%, respectively. This is compared to 9.0% for breast cancer and 80.0% for lung cancer. 5 year pooled mortality for all reported cancer was 31.0%. Direct costs of care for diabetes in general was $237 billion in 2017. This is compared to $80 billion for cancer in 2015. As up to one-third of the direct costs of care for diabetes may be attributed to the lower extremity, these are also readily comparable. Diabetic lower extremity complications remain enormously burdensome. Most notably, DFU and LEA appear to be more than just a marker of poor health. They are independent risk factors associated with premature death. While advances continue to improve outcomes of care for people with DFU and amputation, efforts should be directed at primary prevention as well as those for patients in diabetic foot ulcer remission to maximize ulcer-free, hospital-free and activity-rich days.

Protease-catalyzed polymerization and copolymerization of L-glutamic acid diethyl ester hydrochloride (1) have been performed in a buffer of high concentration. Papain and bromelain showed high catalytic activity toward the polymerization. H-H COSY NMR analysis of the product showed the exclusive formation of poly(alpha-peptide), which was further confirmed by comparison with NMR spectra of poly(alpha-methyl gamma-L-glutamate). The papain-catalyzed polymerization of gamma-methyl L-glutamate did not occur under the similar reaction conditions, supporting the regioselective production of the polymer having an alpha-peptide linkage from 1. The effects of the reaction parameters have been systematically investigated. The copolymerization of 1 with various amino acid esters took place by the papain catalyst to give peptide copolymers.