Patrick G. Harris

Prevention of surgical site infection and appropriateness of antibiotic prescribing habits in plastic surgery

OBJECTIVES The use of antimicrobial prophylaxis against surgical site infection (SSI) is widespread in plastic surgery, while results from prospective randomised controlled trials in guiding antibiotic use are lacking. The purpose of this study was to identify the incidence and risk factors for SSI in plastic surgery, and to evaluate the appropriateness of prophylactic antibiotic prescribing habits in a tertiary university centre. METHODS A retrospective chart review was conducted over a 6-month period. Co-morbidities, types of procedure, prophylactic antimicrobial administration, SSI rates, and clinical outcomes were evaluated. RESULTS The incidence of SSI was 9.3% for 335 procedures. The cumulative incidence of SSI for breast surgery (n=80) was 16.3%, with a 78.8% prescription rate. For head and neck procedures (n=68), the incidence of SSI was 10.3%, with 80.9% of patients receiving antibiotic prophylaxis. For hand and upper limb procedures (n=170), 70.6% of patients received antimicrobial prophylaxis, with a 4.7% SSI incidence. According to category A prophylaxis guidelines published in the plastic surgery literature, over prescribing was identified in 27.5% of breast, 61.8% of head and neck, and 19.4% of hand and upper limb procedures. CONCLUSIONS This is the first study evaluating appropriateness of antimicrobial prophylaxis use by plastic surgeons. Despite widespread use of prophylactic antibiotics, significant SSI rates were still present and frequently responsible for re-hospitalisations and re-interventions. The appropriateness of administration and indications for perioperative prophylactic antibiotic use must be evaluated.

Venous thromboembolism in plastic surgery: incidence, current practice and recommendations☆

Venous thromboembolic events (VTEs) are an important concern due to their frequently asymptomatic presentation and significant morbidity and/or mortality. The true incidence of this disease process is unknown as (i) screening procedures and (ii) prophylaxis protocols are frequently lacking in this patient population. The purpose of this study was to identify published thromboprophylactic recommendations established in the plastic surgery literature and to provide a review on thromboembolism and current methods of prophylaxis. A systematic evaluation of all published guidelines for thromboembolism prophylaxis in plastic surgery was conducted. We report on 24 studies in favour of, and three studies against, mechanical and/or pharmacological prophylaxis. Thromboprophylactic recommendations were published by a small randomised trial (grade B, level 2), six retrospective studies (grade C, level IV), two literature reviews (grade C, level V), two surveys (grade C, level V), three narrative reviews (Continuing Medical Education) (grade C, level V) and 10 expert recommendations (grade C, level V). The three publications against prophylaxis were composed of a retrospective study (grade C, level IV) and two case series with no control group (grade C, level V). There is a significant paucity of category A or B evidence favouring thromboprophylaxis in the plastic surgery patient population. There is a need for further research in established thromboprophylaxis guidelines in plastic and reconstructive surgery.

Preliminary evaluation of infraclavicular catheters inserted using ultrasound guidance: through-the-catheter anesthesia is not inferior to through-the-needle blocks.

Background and Objectives: This prospective study compared the initial block quality and surgical anesthesia rates of ultrasound-guided infraclavicular blocks with local-anesthetic injected through a catheter versus through a needle. We hypothesized that positioning of the catheter immediately posterior to the axillary artery would produce through-the-catheter (TTC) anesthesia with rates of complete block not inferior to through-the-needle (TTN) injection. Methods: Eighty patients undergoing hand or forearm surgery extensive enough to require regional anesthesia were randomized into 2 groups of 40. In group TTN, local anesthetic was deposited posterior, lateral, and medial to the axillary artery using as few injections as necessary. In group TTC, a 20-gauge, multiorifice catheter was positioned between the posterior wall of the axillary artery and the posterior cord of the brachial plexus. All blocks were performed by use of ultrasound visualization with a 6-MHz to 10-MHz 38-mm linear probe. Local-anesthetic solution consisted of 0.5 mL/kg lidocaine 2% with epinephrine. Sensory and motor blocks, as well as supplementation rates, were evaluated for the musculocutaneous, median, radial, and ulnar nerves. Results: Complete sensory block of all nerve territories was achieved in 92% of patients in group TTN and 90% in group TTC (P = .51). In group TTN, 90% of patients had satisfactory anesthesia for surgery (no discomfort and no need for anesthetic supplementation of any type) compared with 92% in group TTC (P = .51). Conclusion: Ultrasound-guided TTC infraclavicular block produced perioperative anesthesia that was not inferior to a TTN technique.

MDCT Arthrography or MR Arthrography for Imaging the Wrist Joint

Imaging of the wrist joint has been radically modified over the last decade, particularly since multidetector computed tomography (MDCT) arthrography and magnetic resonance (MR) arthrography have become widely available. These two modalities allow a confident assessment of ligament tears and potential diagnosis of associated abnormalities of cartilage, bone, and soft tissues. The interosseous scapholunate and lunotriquetral ligaments and the triangular fibrocartilage complex (TFCC) are the most important structures to consider. Precise analysis of their different lesions, including recognition of degenerative tears, is essential for guiding the treatment. After a brief overview of the different injuries of interosseous ligaments and cartilage, this article thoroughly exposes the technical aspects of wrist MDCT arthrography and MR arthrography, reviews their results, and discusses their performances in light of recent literature. Finally, we propose an imaging strategy to decide between MDCT arthrography and MR arthrography depending on the clinical query. Other imaging modalities are not forgotten in this strategy. The evaluation of ligamentous and TFCC pathology must always begin with conventional radiographs. Cineradiography, ultrasound, and standard MRI are also useful in selected cases.

Outcomes in the Management of Sternal Dehiscence by Plastic Surgery : A Ten-Year Review in One University Center

Purpose:Infection rates following median sternotomy vary between 0.2% and 10%. These cases are associated with morbidity and mortality rates between 10% and 25% and 5% and 20%, respectively. The purpose of this study was to evaluate patient outcomes following plastic surgery correction of sternotomy dehiscence (SD). Methods:All patients operated on for an SD following coronary artery bypass graft surgery (CABG), between 1995 and 2005, with 1 or more flaps, were included. Results:Eighty cases were identified over a 10-year period. The mean age was 64 (±9.1) years. Two or more procedures were required in 17.5% of patients, and the mortality rate within 30 days was 12.5%. Significant variability was revealed between the cumulative mortality rates of plastic surgeons, from 0.0% to 50.0%. Multiple associations were identified for poor outcome, including chronic renal insufficiency and early mortality, and obesity with risk of reintervention. Conclusion:Although patients who undergo surgical correction of a deep sternal infection usually tolerate their intervention well, the mortality within 30 days remains high. This study has identified several factors explaining morbidity and mortality in this patient population.

A review of materials currently used in orbital floor reconstruction

Orbital fractures are common fractures of the midface. As such, numerous techniques and materials exist for the repair of this region, each with inherent advantages and disadvantages. But does the ideal implant material exist? Should we stop and simply use readily available materials, or should the cycle of need and discovery continue? A comprehensive review of materials used in orbital reconstruction and possible new directions in orbital floor reconstruction are presented.

Paraspinous muscle flaps for the treatment and prevention of cerebrospinal fluid fistulas in neurosurgery.

Study Design. A prospective clinical study was conducted to evaluate the efficacy of paraspinous muscle flaps in preventing and managing cerebrospinal fluid fistulas in high-risk neurosurgery patients. Objectives. To evaluate the efficacy of paraspinous muscle flap coverage using a “vest-over-pants” closure in the prevention and treatment of cerebrospinal fluid fistulas. Summary of Background Data. Previous studies have described paraspinous muscle flaps for the closure of complex spinal wounds, but none has addressed their use for the prevention and treatment of cerebrospinal fluid fistulas. Methods. This prospective clinical study evaluated nine consecutive patients with either refractory cerebrospinal fluid fistulas or high risk for cerebrospinal fluid leaks after spinal surgery. Bilateral paraspinous muscle flaps were used as primary flaps and closed using an overlapping vest-over-pants technique in eight of nine cases. The latissimus dorsi and trapezius muscles were recruited as additional muscle flaps for closure of thoracolumbar and high thoracic deficits, respectively. Results. Paraspinous muscle flaps provided immediate wound coverage in seven high-risk patients undergoing spinal surgery and two patients with recurrent cerebrospinal fluid fistulas. Postoperative hospitalization averaged 14.4 days. There was no evidence of a cerebrospinal fluid fistula after an average follow-up of 176.7 days. No wound infections occurred. The only complications were a superficial hematoma, which was drained percutaneously on postoperative day 6, and a seroma, which was drained during the follow-up period and eventually resolved. Conclusions. Paraspinous muscle flaps allow effective treatment and prevention of cerebrospinal fluid fistulas in selected high-risk patients and provide simple durable coverage of complex spinal wounds with minimal morbidity.

Bilateral Thumb's Active Range of Motion and Strength in de Quervain's Disease: Comparison with a Normal Sample

The aims of the present study were to characterize the thumb active range of motion (AROM) and strength impairments resulting from unilateral de Quervains disease; to verify the adequacy of standard clinical assessment tools to quantify impairments resulting from this pathology; and to validate the utilization of the asymptomatic thumb as a reference to quantify the symptomatic thumbs deficits by comparing the performances of asymptomatic to control thumbs. The thumbs AROM and strength were evaluated bilaterally in 31 participants with unilateral de Quervains disease and 18 control participants using clinical assessments involving the flexors and adductors of the thumb and experimental assessment devices measuring strength and mobility in several directions of the thumbs movements. A comparison was made between the results obtained from the symptomatic, asymptomatic, and control thumbs. The AROM performance of symptomatic thumbs was found to be reduced when compared to the asymptomatic and control thumbs for maximal thumb flexion (p=0.008 and 0.003, respectively) and total circumduction displacement (p<0.001). The strength performance of the symptomatic thumb was also found to be reduced when compared to the asymptomatic and control thumbs for palmar pinch strength (p<0.001 and 0.002, respectively) and for maximal voluntary effort in all directions (p<0.001). Differences in performance were also found between the asymptomatic and control thumbs, reaching the significance level for some movement parameters of the thumb circumduction evaluations and when palmar pinch strength results are normalized (p<0.001 and 0.009, respectively). This study revealed bilateral impairments of thumb AROM and strength for participants with de Quervains disease, the impairments being more pronounced on the symptomatic side. This finding may question the validity of using the asymptomatic thumb as a standard measure to identify the symptomatic thumbs impairments associated with de Quervains disease. The study also demonstrated the validity of using clinical evaluations when assessing impairments associated with this disease.

Monitoring buried jejunum free flaps with a sentinel: a retrospective study of 20 cases.

The free jejunum transfer has become a widely used reconstruction option after total laryngopharyngectomy. The aim of this study was to evaluate the effectiveness of using an exteriorized jejunal segment for flap monitoring.

Principles of Chest Wall Resection and Reconstruction

Despite significant improvements in surgical technique and perioperative care, the management of patients requiring chest wall resection and reconstruction is an ongoing challenge for thoracic surgeons. A successful approach includes a thorough assessment of the patient and the lesion, an adequate biopsy to confirm tissue diagnosis, and a well-established treatment plan. In the case of a primary tumor of the chest wall, the extent of the resection should not be limited by the size of the resulting defect. Following resection, chest wall reconstruction mandates an appreciation for restoration of functional and structural components. An algorithmic approach to chest wall reconstruction begins with the assessment of the nature of the defect, taking into consideration factors such as infection, tumor location, previous radiation therapy, and surgical intervention. The latter factors bear influence on the type of tissue required as well as whether reconstruction can be performed in a single stage or whether it is better delayed. Finally, patient factors including lifestyle and work, as well as prognosis, are considered to determine the best reconstructive option.