Hannah M. Carl

Systematic Review of the Surgical Treatment of Extremity Lymphedema

Background Although conservative management of lymphedema remains the first‐line approach, surgery is effective in select patients. The purpose of this study was to review the literature and develop a treatment algorithm based on the highest quality lymphedema research. Methods A systematic literature review was performed to examine the surgical treatments for lymphedema. Studies were categorized into five groups describing excision, liposuction, lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and combined/multiple approaches. Studies were scored for methodological quality using the methodological index for nonrandomized studies (MINORS) scoring system. Results A total of 69 articles met inclusion criteria and were assigned MINORS scores with a maximum score of 16 or 24 for noncomparative or comparative studies, respectively. The average MINORS scores using noncomparative criteria were 12.1 for excision, 13.2 for liposuction, 12.6 for LVA, 13.1 for VLNT, and 13.5 for combined/multiple approaches. Loss to follow‐up was the most common cause of low scores. Thirty‐nine studies scoring > 12/16 or > 19/24 were considered high quality. In studies measuring excess volume reduction, the mean reduction was 96.6% (95% confidence interval [CI]: 86.2–107%) for liposuction, 33.1% (95% CI: 14.4–51.9%) for LVA, and 26.4% (95% CI: − 7.98 to 60.8%) for VLNT. Included excision articles did not report excess volume reduction. Conclusion Although the overall quality of lymphedema literature is fair, the MINORS scoring system is an effective method to isolate high‐quality studies. These studies were used to develop an evidence‐based algorithm to guide clinical practice. Further studies with a particular focus on patient follow‐up will improve the validity of lymphedema surgery research.

Abstract 8.40 A POST-OPERATIVE PROTOCOL FOR AUTOLOGOUS FREE FLAP BREAST RECONSTRUCTION OPTIMIZING RESOURCES AND PATIENT SAFETY

METHODS: A Markov model was used to simulate the effects of standard prevention compared to tibial neurolysis on the long-term costs associated with foot ulcers and amputations. This model included eight health states. A baseline analysis was built on a five-year model to determine the cumulative incidence of foot ulcers and amputations with each strategy. Subsequently, a cost-effectiveness analysis and cohort-level Markov simulations were conducted with a model composed of 20 six-month cycles. The outcomes explored were quality adjusted life years (QALYs); the incremental cost-effectiveness of tibial neurolysis in comparison with standard treatment and the net monetary benefits of tibial neurolysis. A sensitivity analysis was also performed.

Vascularized Bone Grafting for Reconstruction of Oncologic Defects in the Spine: A Systematic Review and Pooled Analysis of the Literature

Background Resection of primary spinal tumors requires reconstruction for restoration of spinal column stability. Traditionally, some combination of bone grafting and instrumentation is implemented. However, delayed healing environments are associated with pseudoarthrodesis and failure. Implementation of vascularized bone grafting (VBG) to complement hardware may present a solution. We evaluated the use of VBG in oncologic spinal reconstruction via systematic review and pooled analysis of literature. Methods We searched PubMed/MEDLINE, Embase, Cochrane, and Scopus for studies published through September 2017 according to the PRISMA guidelines and performed a pooled analysis of studies with n > 5. Additionally, we performed retrospective review of patients at the Johns Hopkins Hospital that received spinal reconstruction with VBG. Results We identified 21 eligible studies and executed a pooled analysis of 12. Analysis indicated an 89% (95% confidence interval [CI]: 0.75‐1.03) rate of successful union when VBG is employed after primary tumor resection. The overall complication rate was 42% (95% CI: 0.23‐0.61) and reoperation rate was 27% (95% CI: 0.12‐0.41) in the pooled cohort. Wound complication rate was 18% (95% CI: 0.11‐0.26). Fifteen out of 209 patients (7.2%) had instrumentation failure and mean time‐to‐union was 6 months. Consensus in the literature and in the patients reviewed is that introduction of VBG into irradiated or infected tissue beds proves advantageous given decreased resorption, increased load bearing, and faster consolidation. Downsides to this technique included longer operations, donor‐site morbidity, and difficulty in coordinating care. Conclusions Our results demonstrate that complication rates using VBG are similar to those reported in studies using non‐VBG for similar spinal reconstructions; however, fusion rates are better. Given rapid fusion and possible hardware independence, VBG may be useful in reconstructing defects in patients with longer life expectancies and/or with a history of chemoradiation and/or infection at the site of tumor resection.

The Scleroderma Hand: Manifestations of Disease and Approach to Management

Scleroderma is a rare autoimmune connective tissue disorder that often affects the hands. Manifestations in the hands include calcium deposits within the soft tissues that cause pain and may ulcerate through the skin, digital ischemia resulting in chronic wounds and digital gangrene, and joint contracture. Because of the underlying disease, patients with scleroderma have poorly vascularized tissue and a deficient soft tissue envelope, which make surgery particularly challenging. However, when undertaken with care, surgical intervention is often the best option for addressing the disabling hand conditions that so often accompany this disease.

Abstract P31: Surgical Factors Associated with Prolonged Hospitalization After Reconstructive Spinal Surgery

PSRC Abstract Supplement P oter P rofs gel concentrations. Mechanical tests were carried out with an indentation test, and the deformation distance of the gel construct was used as an indicator of relative gel stiffness. A total of 5 different concentrations were used with relative stiffness including: <1, 5, 9, 18 and 25 kPa. The 3D gels were cultured as a single droplet on a 48-well suspension cell culture plate with exchange of fresh media and 100ng/ mL of VEGF-A/C every 2–3 days. The gels were directly observed daily under the light microscope and recorded.

Proximal femur reconstruction using a vascularized fibular epiphysis within a cadaveric femoral allograft in a child with Ewing sarcoma: a case report

Periarticular reconstruction of appendicular bones in skeletally immature patients after tumor resection is a surgical challenge that requires a multidisciplinary approach. The authors present a case of Ewing sarcoma of the proximal femur in an 8-year old girl treated with wide resection of the primary tumor and reconstruction using a vascularized fibula epiphyseal autograft within a cadaveric femoral allograft. The native femoral head was preserved to restore articular anatomy. Postoperative course was without complications. This report demonstrates the use of a vascularized fibula autograft within a cadaveric femoral allograft to optimize growth potential and joint durability in a pediatric patient. ABSTRACT