Raman C. Mahabir

Levels of Evidence in Research Published in The Journal of Bone and Joint Surgery (American Volume) Over the Last Thirty Years

BACKGROUND The recent emphasis on evidence-based medicine has led to increasing levels of evidence being published in surgical journals. The purpose of the present study was to review the levels of evidence in reports published in The Journal of Bone and Joint Surgery (American Volume) over the last thirty years. METHODS We reviewed all of the articles published in The Journal in the years 1975, 1985, 1995, and 2005. Cadaver studies, animal studies, basic-science studies, review articles, Instructional Course Lectures, and correspondence were excluded. Articles were scored according to The Journals levels of evidence for a primary research question. RESULTS A total of 1058 articles were reviewed. Of these, 134, 123, 120, and 174 articles met the inclusion criteria for the years 1975, 1985, 1995, and 2005, respectively, and were ranked according to level of evidence. The number of articles for each level of evidence rating was then expressed as a percentage of the total number of articles meeting the inclusion criteria for that year. There was a significant trend toward higher levels of evidence, with the combined percentage of Level-I, II, and III studies increasing from 17% to 52% (p < 0.01). The percentage of Level-I studies increased from 4% in 1975 to 21% in 2005. The average level of evidence rating improved from 3.72 to 2.90 during the study period. CONCLUSIONS The level of evidence in The Journal has improved significantly over the last thirty years.

Updating the epidemiology of cleft lip with or without cleft palate

Background: Much of the literature on the epidemiology of cleft lip with or without cleft palate is more than three decades old. The question arose as to whether there has been any recent change or trend in its rate of occurrence. Methods: The number of live births with cleft lip or other congenital anomalies was solicited from national and international organizations. Data were collected for 34 states and 30 countries for the years 2002 to 2006. All data were normalized and reported per 10,000 live births. Descriptive statistics, in addition to correlation and regression, were used to analyze the data. Results: Data for the 5-year period demonstrated that the overall congenital anomaly rate increased in the United States and decreased internationally. The states with the highest and lowest rates were Maryland (21.46) and West Virginia (2.59), respectively. The United States cleft lip national rate averaged 7.75. Countries with the highest and lowest rates were Japan (19.05) and South Africa (3.13), respectively. Internationally, the rate of cleft lip declined, with an average overall prevalence of 7.94. Conclusions: The average prevalence of cleft lip with or without cleft palate was 7.75 per 10,000 live births in the United States and 7.94 per 10,000 live births internationally. The trends diverged over the 5-year period, as the rate was stable in the United States and the international rate declined.

A nationwide review of the associations among cervical spine injuries, head injuries, and facial fractures

BACKGROUND : Several small studies have investigated the relationship among facial fractures, c-spine injuries, and head injuries with varying results. Determining this correlation at a national level would be the first step in updating the trauma imaging protocol. The purpose of this study was to review the incidence of facial fractures, c-spine injuries, and head injuries at trauma centers across the United States. METHODS : The design was a retrospective chart review of International Classification of Disease, Ninth Revision, diagnosis and procedure codes from the National Trauma Data Bank between the years 2002 and 2006. This included data on more than 2.7 million reported traumas. RESULTS : The incidence of facial fracture was 13.5% in patients with a c-spine injury, 21.7% in patients with a head injury, and 24.0% of patients with a combined c-spine and head trauma. Head injuries were found in 40.2% of patients with a c-spine injury, 67.9% of patients with a facial fracture, and 71.5% of patients with a combined c-spine injury and facial fracture. C-spine injuries were reported in 6.7% of facial fractures, 7.0% of head injuries, and 7.8% of patients with a combined facial fracture and head injury. CONCLUSIONS : This is the largest review in history documenting these associations. Pending cost-benefit analysis, the current trauma imaging protocol may be challenged.

The prevalence of cervical spine injury, head injury, or both with isolated and multiple craniomaxillofacial fractures.

Background: Several studies have reported the relationship among craniomaxillofacial fractures, cervical spine injuries, and head injuries with varying results. Life-threatening injuries to the head and cervical spine with devastating consequences cannot be missed by reconstructive surgeons during evaluation of facial trauma. The purpose of this study was to establish the prevalence of cervical spine injuries and/or head injuries with isolated and multiple craniomaxillofacial fractures at trauma centers across the United States. Methods: The study was a retrospective chart review of International Classification of Diseases, Ninth Revision diagnosis and procedure codes from the National Trauma Data Bank between the years 2002 and 2006. This included data on over 1.3 million trauma patients from the United States and Puerto Rico. Results: In the setting of an isolated mandible, nasal, orbital floor, malar/maxilla, or frontal/parietal bone fracture, cervical spine injury ranged from 4.9 to 8.0 percent, head injury ranged from 28.7 to 79.9 percent, and concomitant cervical spine and head injury was present in 2.8 to 5.8 percent. In the setting of two or more facial fractures, the prevalence of cervical spine injury ranged from 7.0 to 10.8 percent. The prevalence of head injury ranged from 65.5 to 88.7 percent, and the prevalence of concomitant cervical spine and head injury ranged from 5.8 to 10.1 percent. Conclusion: This article represents the most accurate description of the prevalence of cervical spine and/or head injury with craniomaxillofacial fracture at trauma centers in the United States.

A nationwide review of the treatment patterns of traumatic thumb amputations

AbstractTraumatic thumb amputations are a common problem with significant associated cost to patients, hospitals, and society.The purpose of this study was to review practice patterns for traumatic thumb amputations using the National Trauma Data Bank. By using a large nationwide database, we hoped to better understand the epidemiology and predictors of attempts and successful replantation.The design was a retrospective review of the National Trauma Data Bank between the years 2007 and 2010, investigating patients with traumatic thumb amputations. Analyses of these patients based on replantation attempt, mechanism of injury, and demographics were performed. Comparisons were made between hospitals based on teaching status and on patient volume for replant attempt and success rates.There were 3341 traumatic thumb amputations with 550 (16.5%) attempts at replantation and an overall success rate of 84.9%. Nonteaching hospitals treated 1238 (37.1%) patients, and attempted 123 (9.9%) replantations with a success rate of 80.5%. Teaching hospitals treated 2103 (63.0%) patients, and attempted 427 (20.3%) replantations with a success rate of 86.2%. Being in a teaching hospital increased the odds of attempted replantation by a factor of 3.1 (P < 0.001) when compared to a nonteaching hospital. Treatment at a high-volume center increased the rate of attempted replantation by a factor of 3.4 (P < 0.001), as compared to low-volume hospitals.Practice patterns show that teaching and high-volume hospitals attempt to replant a higher percentage of amputated thumbs. Success rates are similar across practice settings.

Cosmetic surgery training in Canadian plastic surgery residencies: are we training competent surgeons?

BACKGROUND With the demand for cosmetic surgery continuing to rise, it is necessary to reevaluate the current state of cosmetic surgery training during plastic surgery residency. An evaluation of cosmetic surgery training in US plastic surgery residency programs in 2006 identified several areas for improvement, resulting in changes to both the duration and content of training. OBJECTIVES The authors assess the current state of cosmetic surgery training in Canadian plastic surgery residency programs. METHODS A paper survey of all graduating Canadian plastic surgery residents eligible to complete the 2009 Royal College of Physicians and Surgeons of Canada fellowship examinations was performed (N = 29). The survey was conducted primarily at the Canadian Plastic Surgery Review Course in February 2009, with surveys collected from absent residents by e-mail within 1 month after the course. The survey covered 2 broad areas: (1) specifics regarding resident cosmetic surgery training and (2) confidence and satisfaction associated with this experience. RESULTS Of the 29 residents surveyed, 28 responded (96%). The majority of Canadian plastic surgery residency programs (75%) have a designated cosmetic surgery rotation, but 90% of respondents felt it has become increasingly difficult to gain exposure to cosmetic procedures as most are performed at private surgery centers. Elective rotations at cosmetic surgery practices and resident cosmetic clinics were considered the most beneficial for cosmetic surgery education. Residents considered cosmetic surgery procedures of the face (such as rhinoplasty and facelift) more challenging, but they had more confidence with breast and body contouring procedures. CONCLUSIONS Canadian plastic surgery residency programs need to ensure that residents continue to receive comprehensive exposure to both surgical and nonsurgical cosmetic procedures to ensure our specialtys continued leadership in this evolving and highly competitive field. A multidimensional approach utilizing a variety of readily available resources will ensure that the current and future cosmetic surgery educational needs of Canadian plastic surgery residents are met.

Locally administered ketorolac and bupivacaine for control of postoperative pain in breast augmentation patients: part II. 10-day follow-up.

Background: Previously, it was shown that locally applied intraoperative ketorolac and bupivacaine significantly reduced pain in the recovery room. The objective of this study was to test the effectiveness of the same solution over the first 10 days. Methods: This study was a prospective, randomized, double-blind clinical trial with ethical approval. Fifty submuscular breast augmentation patients were enrolled, and informed consent was obtained. Standard anesthetic and surgical protocols were followed. Either normal saline or ketorolac and bupivacaine (30 mg and 150 mg, respectively) were placed into the pocket. The power of this study to detect a 20 percent difference was 0.90, and values of p < 0.05 were considered significant. The primary outcome was pain measured with the visual analogue pain scale recorded in a take-home diary. The secondary outcome was codeine usage. Results: Forty-five patients completed the study. Of the patients who did not, three were in the normal saline group (n = 22) and two were in the ketorolac-bupivacaine group (n = 23). The ketorolac-bupivacaine combination significantly reduced pain over the first 5 days. By the tenth day postoperatively, the effect had dissipated. These patients also used less codeine. There were no significant complications. Conclusion: Locally applied, intraoperative ketorolac and bupivacaine significantly reduced pain for 5 days after surgery in women who had undergone primary breast augmentation.

A practical guide to free tissue transfer.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Evaluate a patient for a reconstructive microsurgery procedure. 2. Discuss the current literature with regard to perioperative patient care. 3. Describe the common microsurgical setup and operating room considerations and anastomotic techniques. 4. List postoperative monitoring, flap salvage, and complications. SUMMARY The purpose of this article is to provide guidelines for maintenance of certification continuing medical education for microsurgical operations. It may be used as an aid in evaluation and management of the microsurgical patient. Interspersed with the maintenance of certification-oriented format is continuing medical education information regarding the current state of practice concerning multiple variables in specific procedures of reconstructive microsurgery.

Core measures: implications for plastic surgery.

Background: Perioperative complications are a major source of morbidity, mortality, and expenditures in health care. Many of these complications are preventable with simple, cost-effective measures when implemented in a standardized manner. Surgical specialties are increasing efforts to implement standardized and easily monitored measures to reduce perioperative complications. Methods: The recommendations provided by the U.S. Department of Health and Human Services and published by the Joint Commission on Accreditation of Healthcare Organizations were summarized as they pertain to plastic surgery. A review of recent plastic surgery literature was pursued to evaluate these recommendations as they pertain to the specialty. Results: Measures exist to reduce the incidence of perioperative infection, venous thromboembolism, and mortality associated with cardiac events. These measures include type and timing of prophylactic antibiotics, maintenance of perioperative normothermia, appropriate hair removal, early discontinuation of urinary catheters, appropriate venous thromboembolism prophylaxis, and use of preoperative beta-blockers. Conclusions: As national quality measures are implemented across an increasing number of specialties, the expansions will likely affect plastic surgery. These measures are evidence based and validated across a diverse group of surgical specialties, resulting in improved measured outcomes. Plastic surgeons would benefit by actively providing leadership as these and similar measures are implemented.

Successful surgical treatment of advanced erythema elevatum diutinum

Erythema elevatum diutinum is a rare, chronic cutaneous vasculitis that presents with plaques or nodules on the extensor surfaces of extremities. Although the exact pathogenesis is unknown, patients usually have an underlying systemic medical problem such as malignancy, autoimmune disease or HIV. Management of the cutaneous manifestations is aimed at controlling the underlying disease process, in addition to medical therapy directed at suppressing the lesions. The difficult case of a 60-year-old man, who was not a candidate for medical therapy but has undergone successful surgical therapy of this rare disease for 10 years, is presented.