Steve J. Kempton

A systematic review of distraction osteogenesis in hand surgery: what are the benefits, complication rates, and duration of treatment?

Background: This work analyzes the utility of distraction osteogenesis as a surgical option for the management of acquired and traumatic hand deformities through a systematic review of the published literature. Methods: A PubMed search for articles reporting results of distraction osteogenesis in the hand was performed. Data collected included age, sex, cause, bone distracted, latency period, distraction rate, consolidation period, treatment time, length gained, and complications. Proportion data variables were compared using the chi-square test. A meta-analysis was also performed to assess the size effect of variables on complication development. Results: Thirty articles (424 distractions) met inclusion criteria. The average length gained from distraction was 2.2 cm; the average total treatment time was 116 days; the average complication rate was 26.4 percent. Proportion analysis, including all articles, showed that congenital cause had significantly fewer complications compared with traumatic cause (p = 0.0129). A lower complication rate in pediatric patients compared with adults approached but did not reach significance (p = 0.0507). Studies that underwent meta-analysis, including only articles comparing both variables of interest, were homogeneous (I2 < 25) and without publication bias (Kendall’s tau p > 0.05 and symmetric funnel plot). None of the variables analyzed by meta-analysis had a significant odds ratio for complication development (p > 0.05). Conclusion: Despite distinct advantages, distraction osteogenesis is associated with a long duration of treatment and high complication rates, particularly in adults and in posttraumatic reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Aggressive Digital Papillary Adenocarcinoma: Case Report of a Positive Sentinel Lymph Node and Discussion of Utility of Sentinel Lymph Node Biopsy.

Aggressive digital papillary adenocarcinoma (ADPA) is an uncommon eccrine sweat gland tumor of the distal extremities that is associated with a high rate of local recurrence and distant metastasis. Current opinion suggests that sentinel lymph node evaluation should be done for high-risk tumors where lymph node spread is a concern. Despite documented spread to regional lymph nodes, information on sentinel lymph node status in ADPA is reported infrequently, with only 1 documented case of positive findings. We report on a case of ADPA of the right long finger where sentinel lymph node biopsy was done and positive for metastases in the axilla, resulting in a subsequent completion lymphadenectomy. To determine the benefit of sentinel lymph node biopsy in ADPA, there is a need for more cases of sentinel lymph node evaluation along with data on local recurrence and distant metastasis in those with positive and negative findings.

Making Master Surgeons Out of Trainees: Part I. Teaching Surgical Judgment.

Summary: The training of competent and ethical plastic surgery residents has become more difficult, as surgeons face increasing clinical and research demands, concern for medicolegal liability, and pressure to increase efficiency to decrease health care expenditures. The resulting variation in operative experience among plastic surgery trainees exemplifies the need for educational reform to accommodate change. Although the Accreditation Council for Graduate Medical Education has mandated a transition to competency-based training, and state-of-the-art technologies in surgical simulation are being developed to improve operative skills, the construction of a system to teach and assess operative judgment is deficient and should be thoughtfully created and implemented. Established educational methods and curriculums can be used in this effort and include apprenticeship operative teaching, surgical simulation, morbidity and mortality conferences, and resident clinics. The first step in this effort is to require trainees to make decisions, communicating their judgments and recommendations using language that demonstrates clear thinking and thoughtful analysis. For faculty, this means carving out dedicated preoperative teaching time in addition to efficient use of intraoperative time and sharing of postoperative outcomes. For programs, this means developing metrics to evaluate progress and build procedure-specific simulations. The goal should be not just to settle for training safe and ethical surgeons but to produce masterful surgeons with mature judgment.

Benefits of the Retrocaruncular Approach to the Medial Orbit: A Clinical And Anatomic Study.

BackgroundCurrent trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. Methods(1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. Results(1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. ConclusionsMedial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix.

Abstract 96: the venous anastomotic flow-coupler for free flap monitoring: a prospective analysis of 85 microsurgical breast reconstruction cases.

PurPose: The venous anastomotic flow-coupler has recently been developed for clinical use, contributing to a multitude of flap monitoring devices and techniques. To date, only one published small retrospective series (19 patients) reported this device to be both reliable and accurate for use in head and neck reconstruction; however, no data exists in the setting of abdominal based free flaps for breast reconstruction. The authors present a prospective analysis of the venous anastomotic flow coupler in 85 microsurgical breast reconstruction cases.

A prospective randomized trial comparing the effects of lidocaine in breast reduction surgery

Background: Use of dilute epinephrine tumescent solution in breast reduction surgery has been shown to significantly decrease operative blood loss without increasing perioperative complications. Lidocaine is commonly added to epinephrine to decrease postoperative pain. Evidence supporting this practice, however, is limited, and lidocaine toxicity has been reported. Methods: With institutional review board approval, patients undergoing bilateral breast reduction surgery were assigned to receive either tumescent saline solution with epinephrine (1:1 million) (group 1), or tumescent saline solution with epinephrine (1:1 million) and lidocaine (0.05%) (group 2). Tumescent solution (500 ml) was infiltrated just before skin incision. Wise pattern reduction with an inferior pedicle was used in all cases. A nurse in the postanesthesia care unit documented immediate postoperative pain and intravenous narcotic use. Patients used a survey to record postoperative pain, nausea/vomiting, and narcotic use for the first 24 hours. Results were analyzed using analysis of variance and logistic regression models. Results: Forty consecutive patients were enrolled (20 in each group). There was no statistical difference between groups 1 and 2 in total intravenous narcotic use (0.89 versus 0.55; p = 0.10), 24-hour narcotic use (32.19 versus 29.47; p = 0.71), peak pain scores both in the postanesthesia care unit (5.47 versus 4.47; p = 0.24) and 24 hours postoperatively surgery (6.44 versus 6.68; p = 0.78), and 24-hour nausea/vomiting counts [group 1, OR, 1.11 (p = 0.87); group 2, OR, 1.87 (p = 0.51)]. There were no hospital admissions in either group. Conclusions: The addition of lidocaine to tumescent solution does not significantly affect postoperative pain following breast reduction surgery. Considering potential risks and added costs, this practice may not be of benefit. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Abstract: The Economic Impact of Skin Cancer

RESULTS: Fifty-five participants (31 patients and 24 parents) completed all questionnaires, 98.2% preferred active involvement in therapeutic decision-making. The SDM-Q-9 scores, assessed by patients and physicians, were acceptable (mean 68 out of 100). However, the independently assessed OPTION-5 scores were significantly lower (mean 31 out of 100). In the consultations, physicians rarely asked for patient preferences regarding involvement. In addition, the patient’s freedom of choice and pros and cons of treatment options were inadequately explained. The degree of patient involvement from the patient’s perspective (CollaboRATE) was significantly correlated with patient satisfaction (ρ 0.35, p<0.01).

Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon

Abstract Background: Patients with spinal cord injury (SCI) requiring reconstructive surgery, particularly for pressure ulcers, are ubiquitous in Plastic and Reconstructive Surgery practices. Much of the current literature focuses on operative techniques, antibiotic indications, sitting protocols, and dressing and bedding choices. Methods: This paper reviews normal neuroanatomy, outlines changes in neurophysiology observed in spinal cord injury, and addresses concepts related to perioperative care that are highly relevant but often under-emphasised. Results: Vascular disturbances such as autonomic dysreflexia and orthostatic hypotension are dangerous phenomena occurring in this patient population that, if not properly recognised and treated, may result in complications such as haematoma, flap loss, inadequate tissue perfusion, and death. The management of spasticity, deep venous thrombosis, and perioperative pain are also relevant and discussed in this paper. Conclusion: A basic understanding of these concepts is essential for the Plastic Surgeon involved in the care of patients with SCI and pressure ulcers, particularly before and after debridement or reconstruction.

Microsurgical Technique Modifications: Practical Tips for Improving Precision.

Supplemental Digital Content is available in the text.