Background:Electrocautery has been a useful, fundamental instrument utilized for surgical procedures since its implementation in the 1920s. However, concerns exist regarding the health hazards of the by-product smoke associated with the use of electrocautery. Methods:A comprehensive review of articles on the composition, mitigation, and effects of smoke was conducted using the PubMed search engine and excluding articles that did not meet the predetermined inclusion criteria. From January 1963 to December 2021, a total of 264 articles resulted, and a total of 69 articles were included in this narrative review. Results:Surgical smoke contains volatile organic compounds, polycyclic aromatic compounds, viral particles, and ultrafine particles. There has been some evidence of mutagenicity to bacterial cells during animal in vivo studies, and one human survey study has shown similar mutagenic effects. We also discuss additional hemostatic techniques that can be used, including the use of hemostatic and antithrombolytic agents, epinephrine infiltration, and the use of tourniquet when appropriate. Conclusions:Further studies should be conducted regarding human effects, but until the data are available, we recommend precautionary measures and actions to protect operating room staff from cautery smoke exposure.

Background: Traumatic ballistic injury is an unfortunate and commonly encountered problem seen by surgeons. An estimated 85,694 nonfatal ballistic injuries occur annually, and in 2020 there were 45,222 firearm-related deaths in the United States. Surgeons of all subspecialties may provide necessary care. Acute care injuries are generally reported to authorities immediately; however, delayed presentation of ballistic injuries may go unreported despite regulations to do so. We present a case of a delayed ballistic injury and a comparative review of individual states’ reporting requirements to highlight statutory obligations and penalties as an educational reference for surgeons treating ballistic injuries. Methods: Google and PubMed searches were performed utilizing keywords “ballistic,” “gunshot,” “physician,” and “reporting” as terms. Inclusion criteria included the English language, official state statute sites, legal and scientific articles, and websites. Exclusion criteria included nongovernmental sites and information sources. Data collected were analyzed to include statute numbers, time to report, infraction consequences, and monetary fines. The resultant data are reported by state and region. Results: All but two state jurisdictions mandate healthcare providers to report knowledge and/or treatment of ballistic injuries, regardless of the timeline of injury. Violations of mandatory reporting may lead to fines or imprisonment, depending on the specific state. The timeline for reporting, fines, and subsequent legal action varies by state and region. Conclusions: Requirements for reporting injuries exist in 48 of 50 states. The treating physician/surgeon should thoughtfully question patients with a chronic ballistic injury history and provide reports to local law enforcement.

Aloe vera has been used for centuries for medicinal purposes. Clinical and experimental evidence indicates usefulness for skin moisturization, promoting wound healing, thermal skin injury, frostbite, and ischemic skin insults. Aloe vera has anti-inflammatory, vasodilatory, antimicrobial, and proliferative actions, which have been investigated in various experimental models and in various in vitro studies. This extensive literature review of the properties and actions of Aloe vera finds substantial evidence for the reported and also likely clinical usefulness for Aloe vera in Plastic Surgery and in wound care and wound healing. Though further clinical investigation is warranted, Aloe vera use may likely be indicated in situations where its effects could positively influence outcomes, such as wound healing, flap vascularity, and inflammatory skin pathologies.

Background An injury to the scapholunate interosseous ligament (SLIL) leads to instability in the scapholunate joint. Temporary fixation is used to protect the ligament during reconstruction or healing of the repair. Rigid screw fixation—by blocking relative physiological motion between the scaphoid and lunate—can lead to screw loosening, pullout, and fracture. Purpose This study aims to evaluate changes in scaphoid and lunate kinematics following SLIL injury and the effectiveness of an articulating screw at restoring preinjury motion. Materials and Methods The kinematics of the scaphoid and lunate were measured in 10 cadaver wrists through three motions driven by a motion simulator. The specimens were tested intact, immediately following SLIL injury, after subsequent cycling, and after fixation with a screw. Results Significant changes in scaphoid and lunate motion occurred following SLIL injury. Postinjury cycling increased motion changes in flexion-extension and radial-ulnar deviation. The motion was not significantly different from the intact scapholunate joint after placement of the articulating screw. Conclusion In agreement with other studies, sectioning of the SLIL led to significant kinematic changes of the scaphoid and lunate in all motions tested. Compared with intact scapholunate joint, no significant difference in kinematics was found after placement of the screw indicating a correction of some of the changes produced by SLIL transection. These findings suggest that the articulating screw may be effective for protecting a SLIL repair while allowing the physiological rotation to occur between the scaphoid and lunate. Clinical Relevance A less rigid construct, such as the articulating screw, may allow earlier wrist rehabilitation with less screw pullout or failure.

Consulting Fee: Acumed, Integra (Binda) A biomechanical study was performed to determine the efficacy of an articulating intercarpal screw for restoring normal scapholunate kinematics following sectioning of scapholunate interosseous ligament (SLIL). We hypothesized that the screw would resist scapholunate (SL) gapping while permitting normal rotational motion of the scaphoid and lunate during simulated wrist motion in a cadaver model. Optoelectronic motion sensors were placed on the scaphoid, lunate, distal radius and 3rd metacarpal of 10 young cadaver wrists. The wrist tendons were loaded with 100N. Cyclic testing of the wrist was performed in flexion/extension (FE), radial/ulnar deviation (RUD) and dart-throwing motion (DTM). Kinematic data was analyzed to determine differential movement of the scaphoid and lunate with 1) SLIL intact, 2) after sectioning the SLIL, 3) after sectioning the SLIL and cycling the wrist through 1000 cycles of flexion/extension, and 4) after SL reduction and placement of the articulating intercarpal screw. Scaphoid and lunate motion for each testing state were compared using repeated measures ANOVA with statistical significance set at P < 0.05. After cutting the SLIL, changes of scaphoid and lunate motion were observed. During FE the scaphoid moved into radial deviation (P = 0.02) and the lunate moved into flexion (P = 0.01). During wrist RUD, the scaphoid moved into ulnar deviation (P = 0.016) and the lunate moved into extension (P = 0.012). During DTM, the scaphoid moved into ulnar deviation (P = 0.03), and the lunate moved into extension (P = 0.04) and ulnar deviation (P = 0.018). After cycling the wrist through 1000 cycles, further changes in motion were observed. During FE, the scaphoid moved into further radial deviation (P = 0.02) and during DTM the scaphoid and lunate both moved into further ulnar deviation (P = 0.046 and 0.042 respectively). Placement of intercarpal screw across the SL joint corrected the motion changes that were observed after SLIL sectioning and motion through 1000 cycles. There was no significant difference in the motion of the scaphoid or lunate during FE, RUD, DTM with the screw in place compared to motion with an intact ligament. Transecting the SLIL and cycling the wrist through 1000 cycles of FE did not produce an SL gap during FE (P = 0.364), RUD (P = 0.290), or DTM (P = 0.524). •Sectioning the SLIL and repetitive cycling of the wrist created significant changes in motion of the scaphoid and the lunate during wrist range of motion.•Placement of an articulating intercarpal screw corrected the changes in scaphoid and lunate motion while permitting independent intercarpal motion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective Anaplastic large cell lymphoma (ALCL) is a rare form of non-Hodgkin T-cell lymphoma potentially associated with silicone-shelled breast implants. The low incidence of ALCL has prevented establishment of causality. Many implantable devices are constructed with biomaterials similar to those used in breast prostheses. The purpose of this paper is to identify reports of ALCL in association with other types of implantable devices. Methods A literature review was conducted using PubMed to identify reports of non-Hodgkin lymphoma in association with various implantable devices. Results One case of ALCL was identified in association with a stainless steel internal fixation plate. Diffuse large B-cell lymphoma was widely reported in association with various implantable biomaterials and chronic inflammation. Conclusion The neoplastic response associated with breast prostheses appears substantively different from other implantable devices. Physicians caring for patients with silicone elastomer-containing implants should have increased suspicion for implant-associated ALCL and report all pertinent cases in the literature.

OBJECTIVE:Anaplastic large cell lymphoma (ALCL) is a rare form of non-Hodgkin T-cell lymphoma potentially associated with silicone-shelled breast implants. The low incidence of ALCL has prevented establishment of causality. Many implantable devices are constructed with biomaterials similar to those used in breast prostheses. The purpose of this paper is to identify reports of ALCL in association with other types of implantable devices.METHODS:A literature review was conducted using PubMed to identify reports of non-Hodgkin lymphoma in association with various implantable devices.RESULTS:One case of ALCL was identified in association with a stainless steel internal fixation plate. Diffuse large B-cell lymphoma was widely reported in association with various implantable biomaterials and chronic inflammation.CONCLUSION:The neoplastic response associated with breast prostheses appears substantively different from other implantable devices. Physicians caring for patients with silicone elastomer-containing implants should have increased suspicion for implant-associated ALCL and report all pertinent cases in the literature.

Figure 1. Intraoperative photo showing the displaced fracture fragment. DESCRIPTION A 55-year-old white man presented with double vision 2 days after low-velocity blunt force–isolated facial trauma. He complained of persistent vertical and horizontal double vision, particularly with inferior and lateral gaze. He had minimal dentition, but he believed that his teeth aligned normally. A computed tomographic scan demonstrated a right orbital floor fracture.

OBJECTIVE:Fat grafting is used to improve the reconstructed breast. Local recurrences following mastectomy present as palpable subcutaneous nodules; fat necrosis/oil cysts, a sequelae of fat grafting, also present as subcutaneous nodules. Our objective was to examine the frequency and factors associated with fat necrosis in the postmastectomy reconstructed breast and propose an algorithm for management.METHODS:A retrospective review of a breast reconstruction database was conducted to identify patients treated with fat grafting. Clinical-pathologic data at cancer presentation, volume of fat injection, occurrence of subcutaneous nodules, and outcome were collected. Statistical analysis was performed to compare the development of a palpable mass with continuous and categorical variables.RESULTS:A total of 278 patients who had fat grafting with breast reconstruction were identified. Sixty-four patients (23%) developed a palpable mass at a median time of 10 months (range: 2-39). Seventeen (6%) subsequently underwent needle or excisional biopsy (16 fat necrosis/oil cysts; 1 recurrent carcinoma). The recurrent carcinoma identified did not correlate with the location of fat grafting. No clinical-pathologic (age, body mass index, stage, smoking, radiation) or technical variables (fat/tumescent volume) were found to predict development of fat necrosis.CONCLUSIONS:Fat grafting improves cosmesis but has a significant risk of fat necrosis. Awareness of fat injection location, incidence, time to development, and characteristic examination may decrease anxiety and need for imaging/biopsy.

DESCRIPTION A 39-year-old man presented with a 5-day history of increasing left eye swelling and erythema, after a palm tree branch struck his face.

A 73-year-old man receiving heparin developed a large hematoma in the first web after a routine blood draw. Color Doppler ultrasound demonstrated a pseudoaneurysm of the princeps pollicis artery. Ultrasound-guided compression resulted in successful thrombosis of the pseudoaneurysm. (Copyright (C) 2012 by the American Society for Surgery of the Hand. All rights reserved.)

OBJECTIVES:To compare the in vitro and in vivo effects of silver products on wound healing.METHODS:Eight silver products were compared to determine: fibroblast function using fibroblast-populated collagen lattices (FPCLs), fibroblast viability using the Trypan Blue exclusion test, and fibroblast mitochondrial activity using the MTT [yellow tetrazolium salt; 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay. In vivo effects of 9 silver products were evaluated utilizing a rat model of contaminated wounds. Serial quantitative bacteriology was performed on tissue biopsies over a 10-day period and serial wound areas were obtained over 12 days.RESULTS:Fibroblast cytotoxicity occurred for all of the silver products evaluated. Remaining viable fibroblasts were insufficient to allow FPCL contraction. Mitochondrial activity of the fibroblasts allowed a separation of the various silver compounds. Actisorb Silver and Silvercel had the greatest viable fibroblast activity, but less than the control. Despite in vitro cytotoxicity, all of the silver products except Contreet Foam and Acticoat Moisture Control accelerated wound healing.CONCLUSIONS:Silver-containing dressings appeared to benefit healing of the wounds. Just as in vitro bacterial analyses do not fully predict the effect of an antimicrobial in the in vivo setting, in vitro cytotoxicity tests do not fully predict the effect of an agent on wound healing trajectories. Because of the varied antimicrobial and wound healing responses among products, a careful consideration of the particular effects of individual silver-containing dressings or drugs is warranted.