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Background:. Timely distribution of research is crucial for improving treatments and patient care; however, the publication process is historically unhurried. The primary goal of this study was to analyze the time to publication in hand surgery for 5 years and to examine potential factors affecting publication speed. Methods:. A 5-year review (2017–2021) was performed on 4 major hand surgery journals. The Journal of Hand Surgery American Volume, Journal of Hand Surgery European Volume, Journal of Plastic Surgery and Hand Surgery, and Plastic and Reconstructive Surgery were included in the review. Differences were assessed using analysis of variance or 2-sided independent t tests for continuous variables. Results:. There was a significant difference in submission-to-publication time between journals (P < 0.001). This differed by year (P < 0.001), with a significant increase in time from submission to publication after 2019, during the COVID-19 pandemic (447 ± 198 versus 406 ± 169 d, P < 0.001). Geographic region of the primary institution did affect submission-to-publication time (P < 0.001). No significant difference was seen in submission-to-publication time based on the number of institutions contributing, article type, or first author or corresponding author surgical specialty (P > 0.05). Conclusions:. Time to publication in hand surgery varies by hand surgery journal and significantly increased during the COVID-19 pandemic. New research reflects work done over a year ago at least. Participation in the peer-review process should be encouraged and bolstered within the hand surgery community to improve research dissemination times within the field.

Background:. Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods:. We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a “surgical pause” (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results:. A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions:. The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence:. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background:. As the incidence of shoulder arthroplasty rises at exponential rates, race is an important consideration, as racial disparities have been reported in lower-extremity arthroplasty in the United States. Our study sought to examine these disparities. Methods:. Using the National Inpatient Sample (NIS) database, all anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (RSA) procedures from 2011 to 2017 were analyzed. The patients were divided into the Black, Hispanic, and White groups. Results:. Overall, 91.4% of the patients undergoing any shoulder arthroplasty procedure were White, 4.75% were Black, and 3.85% were Hispanic. Age and sex-standardized RSA utilization rates (per 100,000) in White patients increased by 139% from 6.94 in 2011 to 16.60 in 2017. The disparity for Black patients, compared with White patients, was 118% in 2011 and 124% in 2017; the disparity for Hispanic patients was 112% in 2011 and 103% in 2017. Similar disparities in aTSA utilization rates were seen; when compared with White patients, there was a 150% disparity in 2011 and a 197% disparity in 2017 for Black patients, and a 169% disparity in 2011 and a 262% disparity in 2017 for Hispanic patients. Finally, Blacks had a higher rate of non-home discharge, longer length of stay, and higher overall costs, while Hispanics had a longer length of stay and higher cost than Whites. Conclusions:. Despite many efforts to reduce racial disparities in health-care utilization, the chasm in shoulder arthroplasty in the United States appears to be large and widening further. The exponential increase in utilization of shoulder arthroplasty has not been shared equally among races, and the disparities are larger than those reported in lower-extremity arthroplasty.

Background:. Pan-facial fracture repair is considered one of the most challenging complex reconstructive procedures to perform. It is always better to treat facial fractures as soon as possible. A delay of several days or weeks makes an ideal anatomic reduction difficult, if not impossible. Methods:. Patients presenting late with noncompound pan-facial fractures and interrupting maxillary and mandibular arches who were candidates for ORIF were included. Patients had been divided randomly into two groups: group A was managed by the ordinary sequence of repair, and group B was managed with the aid of occlusal dental splint. Results:. In total, 20 patients presented late (3–9 weeks post insult) due to serious injuries that required previous intervention. The time until obtaining optimal occlusion ranged between 80 and 120 minutes in the study group, whereas in the control group, the time ranged between 120 and 180 minutes (P < 0.0001). Postoperative malocclusion was noticed to be less frequent in the splint group than in the control group: only one patient with residual malocclusion in the study group versus two patients in the control group. Conclusions:. Occlusal splints could be a good modality for restoring the pre-morbid occlusion in patients with delayed pan-facial fractures. It is a simple, reliable technique that could be easily integrated into our daily practice, and could help decrease the intraoperative time needed for restoration of optimal occlusion and decrease the postoperative malocclusions.

OBJECTIVES:. To assess 30-day mortality in coronavirus disease 2019 acute respiratory distress syndrome patients transferred from rural Appalachian hospitals. DESIGN:. Retrospective case controlled, based on consecutive patients transferred and admitted from rural hospitals to a tertiary-care ICU. The primary outcome was all-cause 30-day mortality. Kaplan-Meier method and log-rank test were used in the survival data analysis. SETTING:. Medical ICU, West Virginia University Hospital, Morgantown, WV. PATIENTS:. All adult patients admitted to the ICU for coronavirus disease 2019 disease between September 30, 2020, and December 2, 2020. INTERVENTION:. Not applicable. MEASUREMENTS AND MAIN RESULTS:. Seventy-nine consecutive coronavirus disease 2019 patients were admitted to the ICU during the defined period. Overall mortality of the cohort was 54%. Of the 79 patients, 50 were transferred from critical access hospitals/rural facilities with coronavirus disease 2019–induced acute respiratory distress syndrome. A control group consisted of 39 patients admitted to the ICU with noncoronavirus disease 2019 acute respiratory distress syndrome who were intubated and mechanically ventilated. Thirty-day mortality in patients with coronavirus disease 2019 admitted to the ICU was significantly higher than the control group (68% vs 42%) (p = 0.034). Mean Sequential Organ Failure Assessment scores were similar in both coronavirus disease 2019 acute respiratory distress syndrome group and controls. Intubation in patients 70 years or older and mechanical ventilation for over 5 days was associated with significantly higher mortality. CONCLUSIONS:. Our data on critically ill and mechanically ventilated coronavirus disease 2019 acute respiratory distress syndrome patients transferred from critical access hospitals/rural facilities have increased mortality compared with noncoronavirus disease 2019 acute respiratory distress syndrome controls. These data suggest that lack or delay in access to tertiary care may impact coronavirus disease 2019 outcome in rural areas. Intubated patients 70 years old or more and mechanical ventilation for over 5 days may be a risk factor for increased mortality. These data may help physicians and hospital administrators in rural areas for optimal utilization of limited resources.

Background:. It has been postulated that the process of—and stresses associated with—medical training may cause a loss of empathy among trainees. Because empathy is considered an important value for clinicians and may even be associated with better patient outcomes, we assessed the empathy of orthopaedic surgery trainees and identified factors associated with empathy. Methods:. Between June and September 2020, an anonymous survey was distributed electronically to trainees in 23 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs via the Collaborative Orthopaedic Educational Research Group. The survey comprised the validated Short-Form 8-Item Empathy Quotient (EQ-8) questionnaire—scored on a scale of 0, least empathetic, to 16, most empathetic—and single-item measure of emotional exhaustion and depersonalization derived from the Maslach Burnout Index—scored using a frequency scale. In total, 438 of 605 (72%) trainees completed the survey. The scores were compared via one-way analysis of variance, with Bonferroni correction and Tukey post-hoc testing, α = 0.05. Results:. The mean (±SD) EQ-8 score among respondents was 11.3 ± 3.3. Women scored significantly higher (mean, 12.2 ± 2.8) than men (mean, 11.2 ± 3.3) (p = 0.02). Mean scores were significantly higher for trainees planning on a career in academic medicine (12.0 ± 2.9) than those intending to pursue private practice (10.9 ± 3.3) or those with a military commitment (10.4 ± 3.4) (p = 0.01). An inverse relationship was found between EQ-8 scores and single-item Maslach Burnout Index measures in depersonalization and emotional exhaustion (both, p < 0.01). No significant differences were found in EQ-8 scores across postgraduate year, program location, primary training setting, intended fellowship, relationship status, or whether they reported having children. Conclusions:. We found no association between postgraduate year and EQ-8 score. Women and those intending to pursue a career in academic medicine had significantly higher levels of empathy. A significant inverse relationship was found between burnout and empathy. Respondents with higher levels of emotional exhaustion and depersonalization had lower levels of empathy.

Background:. Existing data on the epidemiology of shoulder arthroplasty are limited to future projections of incidence. However, the prevalence of shoulder arthroplasty (the number of individuals with a shoulder arthroplasty alive at a certain time and its implications for the burden of revision procedures) remains undetermined for the United States. Hence, the purpose of this study was to estimate the prevalence of shoulder arthroplasty in the United States. Methods:. The National Inpatient Sample (NIS) was queried to count all patients who underwent total shoulder arthroplasty (TSA), including both anatomic and reverse TSA, and hemiarthroplasty between 1988 and 2017. The counting method was used to calculate the current prevalence of TSA and hemiarthroplasty using age and sex-specific population and mortality data from the U.S. Census Bureau. Results:. In 2017, an estimated 823,361 patients (95% confidence interval [CI], 809,267 to 837,129 patients) were living in the United States with a shoulder replacement. This represents a prevalence of 0.258%, increasing markedly from 1995 (0.031%) and 2005 (0.083%). Female patients had a higher prevalence at 0.294% than male patients at 0.221%. Over 2% of people who were ≥80 years of age in the United States were living with a shoulder replacement. Furthermore, approximately 60% of patients living with a shoulder replacement had undergone the operation between 2013 and 2017. The incidence of revision shoulder arthroplasty is increasing on an annual basis, with 10,290 revision procedures performed in 2017, costing the U.S. health-care system $205 million. Conclusions:. The prevalence of shoulder arthroplasty in the United States has markedly increased over time. This trend will likely continue given increasing life expectancies and exponentially increasing shoulder arthroplasty incidence rates. Most patients do not have long-term follow-up, and revision shoulder arthroplasty rates are increasing, a trend that is projected to continue. The data from our study highlight the enormous public health impact of shoulder replacement and shed light on a potentially increasing revision burden.

Objectives:. To understand how patients and family members experience dehumanizing or humanizing treatment when in the ICU. Design:. Qualitative study included web-based focus groups and open-ended surveys posted to ICU patient/family social media boards. Focus groups were audio recorded and transcribed. Social media responses were collected and organized by stakeholder group. Data underwent qualitative analysis. Setting:. Remote focus groups and online surveys. Patients:. ICU patient survivors, family members, and ICU teams. Interventions:. Not available. Measurements and Main Results:. Semi-structured questions and open-ended survey responses. We enrolled 40 patients/family members and 31 ICU team members. Focus groups and surveys revealed three primary themes orienting humanizing/dehumanizing ICU experiences: 1) communication, 2) outcomes, and 3) causes of dehumanization. Dehumanization occurred during “communication” exchanges when ICU team members talked “over” patients, made distressing remarks when patients were present, or failed to inform patients about ICU-related care. “Outcomes” of dehumanization were associated with patient loss of trust in the medical team, loss of motivation to participate in ICU recovery, feeling of distress, guilt, depression, and anxiety. Humanizing behaviors were associated with improved recovery, well-being, and trust. “Perceived causes” of dehumanizing behaviors were linked to patient, ICU team, and healthcare system factors. CONCLUSIONS:. Behaviors of ICU clinicians may cause patients and families to feel dehumanized when in the ICU. Negative behaviors are noticed by patients and families, possibly contributing to poor outcomes including mental health, recovery, and lack of trust in ICU teams. Supporting ICU clinicians may enable a more empathic environment and in turn more humanizing clinician-patient encounters.

Objectives:. Given finite ICU bed capacity, knowledge of ICU bed utilization during the coronavirus disease 2019 pandemic is critical to ensure future strategies for resource allocation and utilization. We sought to examine ICU census trends in relation to ICU bed capacity during the rapid increase in severe coronavirus disease 2019 cases early during the pandemic. Design:. Observational cohort study. Setting:. Thirteen geographically dispersed academic medical centers in the United States. Patients/Subjects:. We obtained daily ICU censuses from March 26 to June 30, 2020, as well as prepandemic ICU bed capacities. The primary outcome was daily census of ICU patients stratified by coronavirus disease 2019 and mechanical ventilation status in relation to ICU capacity. Interventions:. None. Measurements and Main Results:. Prepandemic overall ICU capacity ranged from 62 to 225 beds (median 109). During the study period, the median daily coronavirus disease 2019 ICU census per hospital ranged from 1 to 84 patients, and the daily ICU census exceeded overall ICU capacity for at least 1 day at five institutions. The number of critically ill patients exceeded ICU capacity for a median (interquartile range) of 17 (12–50) of 97 days at these five sites. All 13 institutions experienced decreases in their noncoronavirus disease ICU population, whereas local coronavirus disease 2019 cases increased. Coronavirus disease 2019 patients reached their greatest proportion of ICU capacity on April 12, 2020, when they accounted for 44% of ICU patients across all participating hospitals. Maximum ICU census ranged from 52% to 289% of overall ICU capacity, with three sites less than 80%, four sites 80–100%, five sites 100–128%, and one site 289%. Conclusions:. From March to June 2020, the coronavirus disease 2019 pandemic led to ICU censuses greater than ICU bed capacity at fives of 13 institutions evaluated. These findings demonstrate the short-term adaptability of U.S. healthcare institutions in redirecting limited resources to accommodate a public health emergency.

Abstract. Purpose:. The Surgical Implant Generation Network (SIGN) intramedullary nail was designed for use in resource limited settings which often lack fluoroscopy, specialized fracture tables, and power reaming. A newer design iteration, the SIGN Fin nail, was developed to further simplify retrograde femoral nailing by making proximal interlocking screw placement unnecessary. Instead, the leading end of the Fin nail achieves stability through an interference fit within the proximal femoral canal. While the performance of the traditional SIGN nail has been reported previously, no large series has examined long-term clinical and radiographic outcomes of femoral shaft fractures treated with the SIGN Fin nail. Methods:. The SIGN online surgical database was used to identify all adult femoral shaft fractures treated with the SIGN Fin nail since its introduction. All patients with minimum 6 month clinical and radiographic follow-up were included in the analysis. Available demographic, injury, and surgical characteristics were recorded. Fracture alignment was evaluated on final follow-up radiographs using a previously validated on-screen protractor tool. Coronal and sagittal plane alignment measurements were recorded as deviation from anatomic alignment (DFAA), with units in degrees. Fracture healing was assessed on final follow-up radiographs, with union defined as any bridging callus and/or cortical remodeling across one cortex on orthogonal views. Clinical outcomes available in the database included knee range of motion (ROM) greater than 90° and weight-bearing status at final follow-up. Clinical and radiographic outcomes were then compared between patients with united and nonunited fractures. Results:. The database query identified 249 femoral shaft fractures stabilized with the Fin nail in 242 patients who had minimum 6 month clinical and radiographic follow-up. Final follow-up radiographs were performed at an average of 48 weeks postoperatively. Average coronal and sagittal plane alignment measured on final follow-up radiographs were 2.18° and 2.58°, respectively. The rate of malalignment (DFAA > 10° in either plane) at final follow-up was 6%. Two hundred twenty-nine fractures (92%) were united at final follow-up. Overall, 209 (84%) of patients achieved full weight bearing and 214 (86%) achieved knee ROM >90° at final follow-up. Compared to patients with united fractures, those with nonunion were less likely to achieve full weight bearing (20% vs 90%, P 90° (30% vs 91%, P

Background:. The coronavirus disease 2019 (COVID-19) pandemic led to a drastic decline in the number of elective surgeries performed in the United States. Many national societies and local governments provided recommendations for surgeons to initially suspend and progressively resume elective surgery. The authors used a survey to the American Council of Academic Plastic Surgeons (ACAPS) to assess the effect on plastic surgeons. Methods:. An electronic survey questionnaire was distributed to 532 members of ACAPS. Data on individual and plastic surgery practice demographics, COVID-19 prevention measures, and procedures or services that were being performed or delayed were collected and analyzed. Results:. An estimated 161 members (30.2%) completed the survey. Changes in hospital policy were cited as the most common reason (89%) for determining which procedures were currently offered. Results vary by specialty. Notably,

Background:. The novel coronavirus and associated Coronavirus Disease 2019 (COVID-19) is rapidly spreading throughout the world, with robust growth in the United States. Its drastic impact on the global population and international health care is swift, evolving, and unpredictable. The effects on orthopaedic surgery departments are predominantly indirect, with widespread cessation of all nonessential orthopaedic care. Although this is vital to the system-sustaining measures of isolation and resource reallocation, there is profound detriment to orthopaedic training programs. Methods:. In the face of new pressures on the finite timeline on an orthopaedic residency, the Emory University School of Medicine Department of Orthopaedics has devised a 5-pronged strategy based on the following: (1) patient and provider safety, (2) uninterrupted necessary care, (3) system sustainability, (4) adaptability, and (5) preservation of vital leadership structures. Results:. Our 5 tenants support a 2-team system, whereby the residents are divided into cycling “active-duty” and “working remotely” factions. In observation of the potential incubation period of viral symptoms, phase transitions occur every 2 weeks with strict adherence to team assignments. Intrateam redundancy can accommodate potential illness to ensure a stable unit of able residents. Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters, whereas remotely working residents participate in daily video-conferenced faculty-lead, case-based didactics and pursue academic investigation, grant writing, and quality improvement projects. To sustain this, faculty and administrative 2-team systems are also in place to protect the leadership and decision-making components of the department. Conclusions:. The novel coronavirus has decimated the United States healthcare system, with an unpredictable duration, magnitude, and variability. As collateral damage, orthopaedic residencies are faced with new challenges to provide care and educate residents in the face of safety, resource redistribution, and erosion of classic learning opportunities. Our adaptive approach aims to be a generalizable tactic to optimize our current landscape.

Background:. Vague recommendations regarding elective surgery have been proposed by national organizations in an attempt to conserve personal protective equipment and to protect healthcare workers during the coronavirus disease 2019 pandemic. In response, some states have attempted to provide more clear guidance. Methods:. An internet search was performed to identify and analyze what guidance each state published through government websites through April 10, 2020. Results:. Thirty-five states and the District of Columbia published guidance in the form of either a recommendation or a mandate. Procedures relating to cosmetics and malignancy were found to be mentioned in 4 and 12 states, respectively, but ultimately lacked case-specific information. Conclusions:. Current government and state recommendations do not provide clear guidance on how plastic and reconstructive surgeons should approach elective surgeries. Ultimately, it is the responsibility of all plastic and reconstructive surgeons to operate under appropriate law while individualizing their practices to best suit the needs of their patients while being mindful of resource limitations and exposure risks.

Purpose: Velopharyngeal insufficiency (VPI) occurs in approximately 11-50% of patients born with cleft palate (CP). Correction of VPI with pharyngoplasty decreases the size of the nasopharyngeal airway, increasing the risk of obstructive sleep apnea (OSA) symptoms, which leads to port-revision in 2-3% of cases. While previous studies have examined the short-term effect of pharyngoplasty on OSA symptoms within a five-year postoperative period, the long-term impact of pharyngoplasty is unknown. Polysomnograms are the gold standard for diagnosis of OSA, but they are not cost-effective and are resource-limited for screening. Thus, we aimed to utilize validated patient-reported outcomes measures (PROMs) to examine the effect of pharyngoplasty on long-term OSA symptoms among patients with CP who are over the age of 14 years. Methods: Patients over the age of 14 years with cleft palate were enrolled from the craniofacial clinics at the University of California, Los Angeles and the Cleft Palate Program at the Orthopaedic Institute for Children. 53 patients were prospectively administered the Patient Reported Outcomes Measurement Information Systems (PROMIS) pediatric version 1.0, sleep-related impairment short form 4a. Retrospective chart review was conducted to collect patient demographic, surgical, and past medical data. PROMIS measures were compared between patients with and without sphincter pharyngoplasty and other potential medical or surgical risk factors of sleep-related impairment, using independent sample t tests. Correlation between PROMIS measures and patient demographics was measured using Pearson’s correlation coefficient. Results: Overall, 53 CP patients (mean age: 21.1 ± 4.5 years, 26 males) over the age of 14 were administered the PROMIS short form. 26 patients (49.1%) were diagnosed with VPI and 20 patients (37.7%) underwent pharyngoplasty. CP patients with history of pharyngoplasty showed significantly increased levels of sleep-related impairment compared to patients who had not undergone pharyngoplasty (p = 0.01). No significant differences were found between patients with and without other potential surgical risk factors, including distraction, hyoid advancement, Le Fort advancement, or septorhinoplasty. Similarly, PROMIS measures did not significantly differ among patients with or without other potential contributing medical risk factors, including preterm birth, congenital cardiac condition, reactive airways disease, or depression. In addition, PROMIS measures did not significantly correlate with BMI values. Conclusions: Pharyngoplasty among patients with CP is associated with increased sleep-related impairment, even after the age of 14 years. While pharyngoplasty cannot be considered causal of long-term OSA, our current study suggests that increased vigilance in long-term validated, quantitative sleep screening may be necessary for patients who have undergone pharyngoplasty with potential considerations for intervention.

Abstract. Purpose:. In developing countries, long bone fractures following trauma are a significant contributor to morbidity, and operating room resources are often limited in these settings. The Surgical Implant Generation Network (SIGN) Fin nail may reduce the challenges of retrograde intramedullary nailing of femoral fractures without fluoroscopy. In contrast to the traditional SIGN nail placed in a retrograde fashion, the Fin nail does not require proximal interlocking screws. Instead, the nail achieves stability through an interference fit within the proximal femoral canal. The purpose of this study is to compare postoperative alignment in femoral shaft fractures treated with either a retrograde SIGN Fin nail or a standard retrograde SIGN nail. Method:. Using the SIGN online surgical database, we identified all femoral shaft fractures treated with a retrograde SIGN Fin nail at 2 African hospitals. Two examiners independently classified fracture patterns using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification system. Using an on-screen protractor tool, postoperative coronal and sagittal plane alignment were measured and recorded as deviation from anatomic alignment (DFAA), with units in degrees. Available patient demographics and surgical details were also recorded. Fin nail cases were matched in a 1:1 ratio to retrograde standard SIGN nail cases based on AO/OTA fracture type. Results:. Twenty-eight retrograde Fin nail cases were identified, and 28 matched retrograde SIGN nail cases were selected. The Fin nail and retrograde SIGN nail groups were well matched in terms of demographics, AO/OTA fracture type, and surgical characteristics. There was no significant difference in postoperative coronal or sagittal plane alignment between the groups. There were no cases in either group of average postoperative malalignment >5° in any plane. Conclusion:. The SIGN Fin nail appears to achieve satisfactory radiographic alignment without the need for proximal interlocking screws, making it an attractive implant for retrograde femoral shaft fracture fixation in resource-limited settings. Further research is required to validate these findings and determine long-term Fin nail clinical outcomes.

Background:. Historically, external ear melanomas have been treated aggressively, due to early perceptions suggesting they had poor prognosis and aggressive biological behavior. More recent evidence has not supported these notions. Methods:. We completed a complete review of the literature involving malignant melanoma of the external ear. We then completed a quantitative analysis on seventy-three cases from 8 reports that contained case-level data, assessing factors that influence recurrence, and assessing characteristics of the melanomas based on histological subtype. Baseline and outcomes data for all 20 studies were then compiled but not statistically evaluated. Results:. In our subanalysis, patients who had recurrence were significantly more likely to have had wedge resection versus wide-local excision, and those with no recurrence were more likely to have undergone wide local excision. Nodular tumors had significantly greater thickness. Overall, conservative excisions provided excellent outcomes. Conclusions:. Conservative treatment for external ear melanoma produces satisfactory outcomes. There is no evidence to support the use of radical amputation and little evidence to support the removal of cartilage or perichondrium. Sentinel lymph node biopsy is warranted only with positive nodes. There is no role for elective neck dissection. The roles for chemo/radiation therapy are unclear and guidelines for other cutaneous melanomas should be followed.

Abstract. Short treatment duration of ledipasvir/sofosbuvir (LDV/SOF) has been successfully used to treat hepatitis C virus (HCV) genotype 1 infection in treatment-naive noncirrhotic patients with viral loads (VLs) under 6 million IU/mL. However, this short duration has not been studied in renal transplant recipients (RTRs), a patient population on lifelong immunosuppression. Here, we describe 3 RTRs who received 8 weeks of LDV/SOF, meeting the standard criteria for shortened treatment duration. All 3 patients tolerated treatment well and achieved sustained virologic response at 12 weeks (SVR 12).

Summary: Infection is a common complication of immediate breast reconstruction that often leads to device removal, a result emotionally devastating to the patient and frustrating for her surgeon. “No-touch” techniques have been used in other surgical disciplines and plastic surgery, but they have not been reported for breast reconstruction with tissue expanders or implants and acellular dermis. We report a novel technique of tissue expander and acellular dermis placement using no-touch principles with a self-retaining retractor system that holds promise to decrease infectious complications of breast reconstruction.