Osama A. Samargandi

The quality of systematic reviews in hand surgery: an analysis using AMSTAR.

1. Jazayeri L, Klausner JQ, Chang J. Distal digital replantation. Plast Reconstr Surg. 2013;132:1207–1217. 2. Koshima I, Soeda S, Moriguchi T, Higaki H, Miyakawa S, Yamasaki M. The use of arteriovenous anastomosis for replantation of the distal phalanx of the fingers. Plast Reconstr Surg. 1992;89:710–714. 3. Kamei K, Sinokawa Y, Kishibe M. The venocutaneous fistula: A new technique for reducing venous congestion in replanted fingertips. Plast Reconstr Surg. 1997;99: 1771–1774. 4. Koshima I, Yamashita S, Sugiyama N, Ushio S, Tsutsui T, Nanba Y. Successful delayed venous drainage in 16 consecutive distal phalangeal replantations. Plast Reconstr Surg. 2005;115:149–154. 5. Baek SM, Kim SS. Successful digital replantation after 42 hours of warm ischemia. J Reconstr Microsurg. 1992;8:455–458; discussion 459.

Pre-existing psychiatric disorder in the burn patient is associated with worse outcomes

OBJECTIVE To compare patient and burn characteristics between patients who had a pre-existing psychiatric diagnosis and patients who did not in a Burn Unit at an academic hospital. BACKGROUND Psychosocial issues are common in patients recovering from a burn; however, little is known regarding hospital course and discharge outcomes in patients with a pre-existing psychiatric diagnosis presenting with a burn. Baseline medical comorbidities of burn patients have been shown to be a significant risk for in-hospital mortality. METHODS A retrospective chart review of 479 consecutive patients admitted to the Burn Unit of an academic hospital in Halifax, Nova Scotia between March 2nd 1995 and June 1st 2013 was performed. Extensive data regarding patient and burn characteristics and outcomes was collected. Patients with and without pre-existing psychiatric diagnoses at the time of hospital admission were compared. RESULTS Sixty-three (13%) patients had a psychiatric diagnosis, with the most common being depression (52%). Forty-percent (n=25/63) of these patients had multiple pre-existing psychiatric diagnoses. Patients with a psychiatric diagnosis had a greater total-body-surface-area (TBSA)% covered by a third-degree burn (p=0.001), and were more likely to have an inhalation injury (p<0.001). These patients were also significantly more likely to experience 6 of the 10 most prevalent in-hospital complications and had a higher mortality rate (p=0.02). They were less likely to be discharged home (p=0.001), and more likely to go to a home hospital (p=0.04) or rehabilitation facility (p=0.03). Psychiatric diagnosis was associated with significantly more placement issues (e.g. rehab bed unavailability, homeless) upon discharge from the Burn Unit (p=0.01). The risk of death in burn patients with pre-existing psychiatric disorders was about three times the risk of death in patients with no psychiatric disorders when adjusting for other potential confounders (95% CI, 1.13-9.10; p-value 0.03). CONCLUSION Presence of a pre-existing psychiatric disorder in the burn patient was associated with worse outcomes and was a significant predictor of death. Psychiatric diagnoses should be identified early in burn treatment and efforts should be made to ensure a comprehensive approach to inpatient support and patient discharge to reduce unfavorable burn outcomes and placement issues.

Why the P-Value Alone is Not Enough: The Need for Confidence Intervals in Plastic Surgery Research

Background: The p value is one of the most used descriptors in statistical analysis; however, when reported in isolation, it does not convey the effect size of a treatment. The reporting of confidence intervals is an essential adjunct to determine the clinical value of treatment, as it permits an assessment of the effect size. The authors assessed the reporting of confidence intervals in clinical trials within the plastic surgery literature. Methods: The seven highest impact plastic surgery journals were screened using MEDLINE for clinical trials in the years 2006, 2009, 2012, and 2015. Studies were randomized based on a predetermined sample size, and various characteristics (e.g., Jadad quality score, reporting of statistical significance, journal impact factor, and participation of an individual with formal research training) were documented. Results: Two independent reviewers analyzed 135 articles. There was substantial interrater agreement (kappa = 0.78). Although 86.7 percent of studies reported a p value, only 25.2 percent reported confidence intervals. Of all journals assessed, Plastic and Reconstructive Surgery most frequently reported confidence intervals. The quality of the studies had a median Jadad score of 2 of 5. Bivariate analysis revealed that higher Jadad score and involvement of an individual with formal research training were associated with reporting of confidence intervals. Multivariate analysis revealed similar findings, whereas journal impact factor, year of publication, and statistical significance were not correlated with confidence interval reporting. Conclusions: Confidence intervals are underreported in the plastic surgery literature. To improve reporting quality of clinical trials, results should always include the confidence intervals to avoid misinterpretation of the effect size of a statistically significant result.

Night Orthosis After Surgical Correction of Dupuytren Contractures: A Systematic Review

PURPOSE To determine the role of night orthosis use after surgical correction of Dupuytren contracture. METHODS We searched MEDLINE, EMBASE, CINAHL, AMED, OTSeeker, and CENTRAL for articles published from inception of the databases to August 2015. Assessment was undertaken by 2 independent reviewers (O.A.S. and S.A.). Methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool and the Newcastle-Ottawa instrument. RESULTS Seven studies met the standard for inclusion in this review. A total of 659 patients across these 7 studies were included in the analysis, with follow-up ranging from 3 to 72 months. None of the included studies assessed recurrence. The analysis revealed no significant improvement in range of motion of hand joints for patients who received a static night orthosis after Dupuytren surgery compared with patients without an orthosis. Similarly, no differences were found in patient-reported functional status across the 2 groups. CONCLUSIONS The current literature does not appear to support the use of static night orthosis in addition to hand therapy after surgical correction of Dupuytren contracture. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

“Assessing the methodological quality of systematic reviews in radiation oncology: A systematic review”

OBJECTIVE The objective of our study was to evaluate the methodological quality of systematic reviews and meta-analyses in Radiation Oncology. METHODS A systematic literature search was conducted for all eligible systematic reviews and meta-analyses in Radiation Oncology from 1966 to 2015. Methodological characteristics were abstracted from all works that satisfied the inclusion criteria and quality was assessed using the critical appraisal tool, AMSTAR. Regression analyses were performed to determine factors associated with a higher score of quality. RESULTS Following exclusion based on a priori criteria, 410 studies (157 systematic reviews and 253 meta-analyses) satisfied the inclusion criteria. Meta-analyses were found to be of fair to good quality while systematic reviews were found to be of less than fair quality. Factors associated with higher scores of quality in the multivariable analysis were including primary studies consisting of randomized control trials, performing a meta-analysis, and applying a recommended guideline related to establishing a systematic review protocol and/or reporting. CONCLUSIONS Systematic reviews and meta-analyses may introduce a high risk of bias if applied to inform decision-making based on AMSTAR. We recommend that decision-makers in Radiation Oncology scrutinize the methodological quality of systematic reviews and meta-analyses prior to assessing their utility to inform evidence-based medicine and researchers adhere to methodological standards outlined in validated guidelines when embarking on a systematic review.

Repair of Primary Cleft Palate and Oronasal Fistula With Acellular Dermal Matrix: A Systematic Review and Surgeon Survey

Objective: The current review and survey aim to assess the effectiveness of acellular dermal matrix (ADM) in the repair of cleft palate and oronasal fistula and to evaluate the current trends of ADM use in palate surgery. Design: A systematic review of English articles was conducted using MEDLINE (1960 to July 1, 2016), the Cochrane Controlled Trials Register (1960 to July 1, 2016), and EMBASE (1991 to July 1, 2016). Additional studies were identified through a review of references cited in initially identified articles. Search terms included “cleft palate,” “palatal,” “oronasal fistula,” “acellular dermal matrix,” and “Alloderm®.” An online survey was disseminated to members of the American Cleft Palate-Craniofacial Association to assess current trends in ADM use in palate surgery. Study Selection: All studies evaluating the outcome of primary palate repair or repair of oronasal fistula with the use of aceullar dermal matrix products were included in the review. Results: Twelve studies met inclusion criteria for review. Studies were generally of low quality, as indicated by methodological index for non-randomized studies (MINORS) scores ranging from 7 to 14. The pooled estimate for fistula formation after primary palatoplasty following ADM use was 7.1%. The pooled estimate for recurrence of fistula after attempted repair using ADM was 11%. Thirty-six cleft surgeons responded to the online survey study. Of these, 45% used ADM in primary cleft palate repair, while 67% used ADM for repair of oronasal fistulae. Conclusion: Use of ADM products is commonplace in palate surgery. Despite this, there is a paucity of high-quality data demonstrating benefit. Further randomized controlled trials examining ADM in palate surgery are required to help develop structured guidelines and improve care.

Abstract: Discrepancies between Registered and Published Primary and Secondary Outcomes in Randomized Controlled Trials within the Plastic Surgery Literature

PURPOSE: Myelomeningocele is the most common congenital malformation of the central nervous system, with a prevalence of 4.4 to 4.6 per 10,000 live births in the United States. They are most commonly observed in the lumbosacral region, as this is the last region of the neural tube to fuse. Robust, reliable and reproducible closure of lumbosacral myelomeningocele defects remains a challenge. Closure of spinal defects following neurosurgical procedures with well-vascularized flaps in high-risk patients has been shown to reduce complications in the adult population. In infants with lumbosacral myelomeningocele, in addition to the relatively standard neurosurgical repair that consists of placode tubularization and dural repair, multiple methods of soft tissue coverage have been described. These include various cutaneous, fascial and muscle flaps and grafts. We present here our unique closure technique with well-vascularized flaps following lumbosacral myelomeningocele repair. METHODS: After the neurosurgical repair of lumbosacral myelomeningocele is completed, bilateral composite latissimus dorsi musculocutanous and gluteus maximus fasciocutanous flaps are elevated. The gluteus maximus fasciocutaneous flaps are completely elevated from their insertion on the ileum and sacrum. The paraspinous muscle flaps are then elevated and medialized based on the lateral row arterial perforators to provide complete muscular coverage of the dural repair. The bilateral composite latissimus dorsi muscleocutanous and gluteus maximus fasciocutanous flaps are medialized, reapproximated with the sacrum, and closed over the paraspinous muscle flap repair.

Abstract: The Impact of Delaying Breast Reconstruction on Patient Expectations and Health Related Quality of Life

METHODS: A retrospective study of patients who underwent immediate breast reconstruction by means of pre-pectoral (Group 1) and sub-pectoral (Group 2) tissue expander placement was performed. Patients in each group were matched for age, BMI, history of neoadjuvant radiotherapy, and type of ADM. Of note, patients in Group 1 received perioperative antibiotic prophylaxis for less than 24 hours while patients in Group 2 received antibiotic prophylaxis for at least 1 week.

Antibiotic Irrigation of Pocket for Implant-Based Breast Augmentation to Prevent Capsular Contracture: A Systematic Review

Background: In vitro and in vivo studies have described a number of different antibiotic solutions for irrigation of the pocket in implant-based breast augmentation in an attempt to prevent the formation of capsular contracture (CC). Our objective was to evaluate the evidence that antibiotic irrigation reduced the rate of CC. Methods: A systematic search of MEDLINE, EMBASE, and CENTRAL was conducted from inception to January 2016. We included studies which examined the use of intraoperative antibiotic irrigation in women undergoing primary breast augmentation. Our primary outcome was the rate of CC. Included studies were assessed for methodological quality using validated tools. Results: Seven studies were included in the final analysis: 1 randomized controlled trial (RCT) and 6 non-randomized studies. The mean follow-up ranged from 14 to 72 months. The rate of CC was less than 2% in 8 studies, between 3% and 6% in 4 studies, and 13.9% in 1 study. Included studies demonstrated significant clinical and methodological heterogeneity. The solitary low-quality RCT concluded that antibiotic irrigation was superior to saline irrigation. Three non-randomized studies demonstrated no significant difference in the rate of CC with the use of antibiotics. One non-randomized controlled study showed that the use of mixture of antibiotic and povidone-iodine significantly lowered the rate of CC. Conclusions: The available evidence on the use of antibiotic irrigation to prevent CC is weak and it is based on studies with high risk of bias. Methodologically robust studies are necessary to answer the question whether antibiotic breast pocket irrigation prevents CC.

Variations in the Anatomical Structures of the Guyon Canal

Background: Compression neuropathy of the ulnar nerve at the Guyon canal is commonly seen by hand surgeons. Different anatomical variations of structures related to the Guyon canal have been reported in the literature. A thorough knowledge of the normal contents and possible variations is essential during surgery and exploration. Objectives: To review the recognized anatomical variations within and around the Guyon canal. Methods: This study is a narrative review in which relevant papers, clinical studies, and anatomical studies were selected by searching electronic databases (PubMed and EMBASE). Extensive manual review of references of the included studies was performed. We also describe a case report of an aberrant muscle crossing the Guyon canal. Results: This study identified several variations in the anatomical structures of the Guyon canal reported in the literature. Variations of the ulnar nerve involved its course, branching pattern, deep motor branch, superficial sensory branch, dorsal cutaneous branch, and the communication with the median nerve. Ulnar artery variations involved its course, branching pattern, the superficial ulnar artery, and the dorsal perforating artery. Aberrant muscles crossing the Guyon canal were found to originate from the antebrachial fascia, pisiform bone, flexor retinaculum, the tendon of palmaris longus, flexor carpi ulnaris, or flexor carpi radialis; these muscles usually fuse with the hypothenar group. Conclusion: The diverse variations of the contents of the Guyon canal were adequately described in the literature. Taking these variations into consideration is important in preventing clinical misinterpretation and avoiding potential surgical complications.