Sheina A. Macadam

Simple Decompression Versus Anterior Subcutaneous and Submuscular Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Meta-Analysis

PURPOSE Optimal surgical management of cubital tunnel syndrome remains uncertain despite the publication of numerous case series, observational studies, systematic reviews, and, in recent years, randomized controlled studies. The purpose of this meta-analysis was to compare simple decompression to anterior transposition of the ulnar nerve for the treatment of this condition, using comparative trials and randomized controlled trials. METHODS Computerized database searches of MEDLINE, EMBASE, Cochrane Central, and all relevant surgical archives were performed. Studies involving adults with cubital tunnel syndrome in whom surgical intervention was simple decompression or anterior transposition (subcutaneous or submuscular) were included. Analysis was limited to randomized controlled trials and comparative observational studies. Included studies were assessed for quality, heterogeneity, and publication bias. Odds ratios of clinical improvement comparing simple decompression to anterior transposition (submuscular or subcutaneous) were calculated for each study. RESULTS Ten studies involving a total of 449 simple decompressions, 342 subcutaneous transpositions, and 115 submuscular transpositions were included. There was little evidence of publication bias or statistical study heterogeneity. Odds of improvement with simple decompression versus anterior transposition were 0.751, 95% confidence interval (0.542, 1.040). Subanalyses on the basis of transposition technique (subcutaneous or submuscular) and study quality did not render a statistically significant result. CONCLUSIONS This report represents the best cumulative evidence to date examining the surgical management of cubital tunnel syndrome. In this study, we found no statistically significant difference, but rather a trend toward an improved clinical outcome with transposition of the ulnar nerve as opposed to simple decompression. Additional prospective, randomized studies that use reproducible preoperative and postoperative objective measures might add statistical power to this finding.

The Use of AlloDerm in Postmastectomy Alloplastic Breast Reconstruction: Part I. A Systematic Review

Background: Postmastectomy alloplastic breast reconstruction is a common procedure that continues to evolve. Increasingly, AlloDerm is being used in both direct-to-implant and two-stage breast reconstruction. The objective of this systematic review was to summarize the outcomes from studies describing this use of AlloDerm, and to compare outcomes to those from studies reviewing non-AlloDerm alloplastic reconstruction. Methods: A computerized search was performed across multiple databases. Studies involving patients undergoing alloplastic breast reconstruction with AlloDerm were included. A systematic review was performed to include randomized controlled trials, comparative observational studies, noncomparative observational studies, and case series. Results: A systematic review of the literature revealed 14 studies that satisfied inclusion criteria. Both acute and long-term complication rates were obtained. No objective validated outcomes were reported. Ninety-three percent of included studies were level IV evidence. Complication rates were as follows: infection, 0 to 11 percent; hematoma, 0 to 6.7 percent; seroma, 0 to 9 percent; partial flap necrosis, 0 to 25 percent; implant exposure with removal, 0 to 14 percent; implant exposure with salvage, 0 to 4 percent; capsular contracture, 0 to 8 percent; and rippling, 0 to 6 percent. No study included a cost analysis. Conclusions: Complications using AlloDerm are comparable to those of non-AlloDerm alloplastic reconstructions. AlloDerm appears to confer a low rate of capsular contracture. A formal analysis is required to determine AlloDerms cost effectiveness in use for direct-to-implant reconstructions. In addition, a randomized controlled trial comparing AlloDerm use to conventional two-stage reconstruction is currently absent from the literature.

Patient satisfaction and health-related quality of life following breast reconstruction: patient-reported outcomes among saline and silicone implant recipients.

Background: In recent years, there has been a growing acceptance of the value of breast reconstruction. The majority of women who choose to proceed will undergo alloplastic reconstruction. The primary objective of this study was to determine whether the type of implant used in alloplastic breast reconstruction has an impact on patient-reported satisfaction and quality of life. Methods: Patients were deemed eligible if they had completed alloplastic reconstruction at least 1 year before study initiation. Patients were contacted by mail: two questionnaires [the BREAST-Q and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (Br23) (EORTC QLQC30 (Br23))], a contact letter, and an incentive gift card were included. Scores were compared between silicone and saline implant recipients. Results: Seventy-five silicone implant recipients and 68 saline implant recipients responded, for a response rate of 58 percent. BREAST-Q responses showed silicone implant recipients to have higher scores on all nine subscales. This difference reached statistical significance on four of nine subscales: overall satisfaction (p = 0.008), psychological well-being (p = 0.032), sexual well-being (p = 0.05), and satisfaction with surgeon (p = 0.019). Regression analysis adjusted for follow-up time, timing of surgery, unilateral versus bilateral surgery, radiation, and age. Results from the EORTC QLQC30 (Br23) showed a statistically significant difference on two of 22 subscales: silicone recipients had higher overall physical function, and saline recipients had higher systemic side effects. Conclusions: This study has shown higher satisfaction with breast reconstruction in silicone gel implant recipients compared with saline recipients using the BREAST-Q. There was no difference in overall global health status between the two patient groups as measured by the EORTC-QLQC30 (Br23).

Nontuberculous mycobacterial breast implant infections.

Background: For reasons that are unclear, the incidence of nontuberculous mycobacterial disease is increasing worldwide. Periprosthetic nontuberculous mycobacterial infections following augmentation mammaplasty and breast reconstruction have been reported previously in the form of case reports. Methods: This retrospective case series examines periprosthetic nontuberculous mycobacterial infections in two western Canadian cities (Edmonton, Alberta, and Vancouver, British Columbia) over a 10-year time period. Results: Ten patients were identified, four of whom had bilateral infections. The most common isolate was Mycobacterium fortuitum. Clinical features were similar to nonmycobacterial periprosthetic infections. The median time to onset of symptoms was 4.5 weeks and the median time to culture an organism was 5.4 weeks. The median duration of antibiotic therapy was 22 weeks. Patients required a mean of three additional operations after diagnosis. Nine patients underwent explantation of the involved implant(s). Reimplantation was performed in six patients a median of 11.5 months after explantation. All cases of reimplantation were successful. Conclusions: Experience with this postoperative complication is limited, as nontuberculous mycobacteria represent a minority of the pathogens responsible for periprosthetic infections. In the absence of specific features with which to identify patients at risk, the surgeon must be aware of the possibility of this infection. To achieve earlier diagnosis, the clinician should have a high index of suspicion in a patient with delayed onset of symptoms, negative preliminary cultures, and a periprosthetic infection that fails to resolve following a course of conventional antimicrobial treatment. With appropriate treatment, nontuberculous mycobacterial periprosthetic infections can be managed successfully.

Outcomes Measures Used to Assess Results After Surgery for Cubital Tunnel Syndrome: A Systematic Review of the Literature

PURPOSE The primary objective of this systematic review was to identify and analyze the outcomes measures that have been used to evaluate postoperative results following surgery for cubital tunnel syndrome. The secondary objective was to compare the postoperative results among patients evaluated using patient-satisfaction instruments to those evaluated using surgeon-reported scales. METHODS Computerized database searches of MEDLINE, EMBASE, and MEDLINE In-Process were performed. Studies involving adults with cubital tunnel syndrome in whom the surgical intervention was simple decompression, anterior transposition (subcutaneous, submuscular or intramuscular), endoscopic decompression, or medial epicondylectomy were included. A systematic review was performed that included randomized controlled trials, comparative observational studies, noncomparative observational studies, and case series. RESULTS This systematic review of the literature identified 42 studies that satisfied the inclusion criteria. The authors identified 21 health outcomes measures used in cubital tunnel studies. These consisted of 2 generic instruments; 10 symptom-specific, author-reported instruments; 3 symptom-specific, patient-reported instruments; and 6 patient questionnaires. No measure demonstrated adequate development or validation for use in its target population. Available data revealed a consistently high level of patient satisfaction following simple decompression or submuscular transposition (65% to 92%). The results of the author-reported, symptom-specific scales varied widely and showed no obvious association with patient satisfaction. The variation in reporting of results prevented statistical comparisons between author-reported results and patient-reported results. CONCLUSIONS To the best of our knowledge, this is the first systematic review to delineate the outcomes measures used to evaluate the treatment of cubital tunnel syndrome. Our results show that reliable, reproducible, and valid outcomes measures are lacking from the surgical literature. A standardized assessment protocol for ulnar neuropathy is required for future comparison trials. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Patient-reported satisfaction and health-related quality of life following breast reconstruction: a comparison of shaped cohesive gel and round cohesive gel implant recipients.

Background: Decision-making in breast reconstruction is complicated as women are offered an increasingly large range of options. Alloplastic surgery continues to evolve with the introduction of new prostheses to the breast reconstruction market but with limited patient-reported outcomes data. Evaluating the outcomes of surgical interventions and their impact on patients is imperative to improve the patient decision-making process and to improve quality of care. The authors evaluated the effect of the two most commonly used silicone prostheses on patient-reported satisfaction and health-related quality of life following alloplastic breast reconstruction. Methods: Patients were deemed eligible if they had completed alloplastic reconstruction at least 1 year before study initiation. Patients were contacted by mail with the BREAST-Q questionnaire, a contact letter, and an incentive gift card. BREAST-Q scores were compared between shaped cohesive and round cohesive silicone gel implant recipients. Results: Sixty-five round, cohesive, non–form-stable and 63 shaped, cohesive, form-stable silicone gel implant recipients responded, for an overall response rate of 75 percent. BREAST-Q responses showed no difference on any scale, including overall satisfaction with breast and outcome. Item-wise analysis revealed that implant recipients find shaped cohesive form-stable implants to be significantly firmer than cohesive round implants. No difference was found in implant rippling. Conclusion: Although previous studies have shown silicone implant recipients to be more satisfied overall than saline implant recipients after alloplastic breast reconstruction, this study showed that patients do not differ in terms of satisfaction with outcome when compared regarding reconstruction using round versus shaped cohesive silicone gel implants. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Acellular dermal matrices: Use in reconstructive and aesthetic breast surgery.

Acellular dermal matrices (ADMs) were first described for use in breast surgery in 2001. Since this initial report, ADMs have become an increasingly common component of implant-based breast procedures. ADMs have shown promise for use in both aesthetic and reconstructive breast surgery; however, concerns about their use remain because of the significant costs associated with these products. The present article reviews the history of ADM use in breast surgery and the outcomes reported to date. Common techniques for placement of ADMs in aesthetic revisionary and breast reconstruction surgery are provided, and use in the setting of chest wall irradiation and capsular contracture is discussed. Finally, the authors comment on the cost implications of these products in the Canadian and American health care systems.

Postmastectomy radiation therapy after immediate two-stage tissue expander/implant breast reconstruction: a University of British Columbia perspective.

Background: An increasing number of women who undergo immediate two-stage tissue expander/implant breast reconstruction will require postmastectomy radiation therapy. An important variable is the timing of radiotherapy relative to surgery. The authors report their experience treating a large consecutive series of patients who underwent postmastectomy radiation therapy to the tissue expander before exchange for a permanent implant. Methods: Patients who had their tissue expander irradiated before implant exchange were identified. Complications, capsular contracture, revision surgery, and autologous salvage rates of irradiated patients were compared with a control group of nonirradiated patients. Results: Immediate two-stage tissue expander/implant reconstruction was initiated in 604 patients, with 113 irradiated breasts meeting inclusion criteria. Three hundred thirty-nine nonirradiated breasts constituted the control group. There was a 4.2 increased odds of major complications in the irradiated group, after adjusting for plastic surgeon, age, body mass index, smoking, chemotherapy, and cancerous breast (OR, 4.2; p = 0.001). The grade III and IV capsular contracture rate was significantly higher in the irradiated group compared with the control group (21.7 percent versus 10 percent; p < 0.008). The revision rate in the control group was higher compared with the irradiated group (30.2 percent versus 20.9 percent; p < 0.001). Conclusions: Postmastectomy irradiation to the tissue expander is associated with high complications; however, these patients have an acceptable capsular contracture rate that compares favorably with other implant-based radiotherapy algorithms. Revision rates were less than expected in irradiated breasts. This study suggests that immediate tissue expander/implant reconstruction is a reasonable surgical option in the setting of postmastectomy radiation therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quality of Life and Patient-Reported Outcomes in Breast Cancer Survivors: A Multicenter Comparison of Four Abdominally Based Autologous Reconstruction Methods

Background: Approximately 20 percent of women select autologous tissue for postmastectomy breast reconstruction, and most commonly choose the abdomen as the donor site. An increasing proportion of women are seeking muscle-sparing procedures, but the benefit remains controversial. It is therefore important to determine whether better outcomes are associated with these techniques, thereby justifying longer operative times and increased costs. Methods: Patients from five North American centers were eligible if they underwent reconstruction by means of the deep inferior epigastric artery perforator (DIEP) flap, muscle-sparing free transverse abdominis myocutaneous (TRAM) flap, free TRAM flap, or the pedicled TRAM flap. Patients were sent the BREAST-Q. Demographics and complications were collected. Results: The authors analyzed 1790 charts representing 670 DIEP, 293 muscle-sparing free TRAM, 683 pedicled TRAM, and 144 free TRAM patients with an average follow-up of 5.5 years. Flap loss did not differ by flap type. Partial flap loss was higher in pedicled TRAM compared with DIEP (p = 0.002). Fat necrosis was higher in pedicled TRAM compared with DIEP and muscle-sparing free TRAM (p < 0.001). Hernia/bulge was highest in pedicled TRAM (p < 0.001). Physical well-being (abdomen) scores were higher in DIEP compared with pedicled TRAM controlling for confounders. Conclusions: Complications and patient-reported outcomes differ when comparing abdominally based breast reconstruction techniques. The results of this study show that the DIEP flap was associated with the highest abdominal well-being and the lowest abdominal morbidity compared with the pedicled TRAM flap, but did not differ from muscle-sparing free TRAM and free TRAM flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cost-effectiveness analysis of implants versus autologous perforator flaps using the BREAST-Q.

Background: Reimbursement has been recognized as a physician barrier to autologous reconstruction. Autologous reconstructions are more expensive than prosthetic reconstructions, but provide greater health-related quality of life. The authors’ hypothesis is that autologous tissue reconstructions are cost-effective compared with prosthetic techniques when considering health-related quality of life and patient satisfaction. Methods: A cost-effectiveness analysis from the payer perspective, including patient input, was performed for unilateral and bilateral reconstructions with deep inferior epigastric perforator (DIEP) flaps and implants. The effectiveness measure was derived using the BREAST-Q and interpreted as the cost for obtaining 1 year of perfect breast health-related quality-adjusted life-year. Costs were obtained from the 2010 Nationwide Inpatient Sample. The incremental cost-effectiveness ratio was generated. A sensitivity analysis for age and stage at diagnosis was performed. Results: BREAST-Q scores from 309 patients with implants and 217 DIEP flap reconstructions were included. The additional cost for obtaining 1 year of perfect breast-related health for a unilateral DIEP flap compared with implant reconstruction was