Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation.

BACKGROUND: Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema. METHODS: This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann-Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL. RESULTS: Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis. CONCLUSION: Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety.

BACKGROUND: As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice. METHODS: A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge. RESULTS: In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient. CONCLUSION: A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.

Functional and Radiographic Outcomes of the Sauvé-Kapandji and Darrach Procedures in Rheumatoid Arthritis.

Background Deterioration of the distal radioulnar joint (DRUJ) in rheumatoid arthritis (RA) manifests as pain, weakness, and reduced range of motion. The Darrach and Sauvé-Kapandji (S-K) procedures are used when medical management fails to control these symptoms. However, there is a paucity of literature comparing the outcomes of these procedures. The purpose of this study is to compare the clinical and radiographic outcomes of the Darrach and S-K procedures in RA patients. Materials and Methods This is a retrospective, single institution cohort study of RA patients who underwent the Darrach or S-K procedure between 2008 and 2016. Ulnar translation, range of motion, and functional improvement were compared. Results Nine patients (13 wrists) underwent the Darrach procedure, and nine patients (11 wrists) underwent the S-K procedure. The average length of follow-up was 1.3 years. Pain, function, and range of motion improved in both groups. The degree of ulnar translation did not significantly change after either procedure. Conclusion Given their similar outcomes, we found no evidence that the S-K procedure is superior to the Darrach procedure or vice versa. However, when surgery is indicated for younger RA patients with DRUJ disease and ulnar translation, the S-K may be better suited to prevent radiocarpal joint dislocation.

Reconstruction options and outcomes for breast sarcoma patients.

Breast sarcomas constitute a rare and heterogeneous group of tumors. Given their aggressive nature and the potential for extensive resections, rates of reconstruction have been low. We retrospectively reviewed subjects derived from our institutional registry presented between 2003 and 2015. Thirty-four patients with primary breast sarcoma were identified. The average age was 51.9 years and the average follow-up was 58 months. The most common histological type was malignant phyllodes (61.8%). Two patients suffered cancer recurrence. Twelve patients (35.3%) underwent reconstruction. Four underwent implant-based reconstruction, seven had autologous-based reconstruction, and one had combined reconstruction. Major complications were one flap loss and one implant removal. Our relatively high rates of breast reconstruction suggest a newly increased willingness to offer reconstruction to this rarer patient population.

Increased Incidence of Symptomatic Venous Thromboembolism following Pedicled Lower Extremity Flap Harvest for Abdominal and Perineal Reconstruction in Patients Receiving Mechanical Prophylaxis and Chemoprophylaxis: A Case for Heightened Awareness.

BACKGROUND: Postsurgical venous thromboembolism remains a leading cause of hospital morbidity. Data to support venous thromboembolism prophylaxis guidelines in lower extremity flap surgery are lacking. The purpose of this study was to explore the effect of pedicled lower extremity flap harvest on venous thromboembolism development in the setting of abdominal or perineal reconstruction. METHODS: One hundred twenty-six patients undergoing unilateral lower extremity flap harvest for abdominal or perineal reconstruction were included. The contralateral leg served as an internal control. Sixty comorbidity-matched patients who underwent abdominal/perineal resection without flap reconstruction provided an external control. Bivariate analyses included chi-square and t tests; logistic regression adjusted for confounding variables on venous thromboembolism development. RESULTS: All patients underwent flap reconstruction for an oncologic defect of the abdomen or perineum, with 80 percent undergoing perineal reconstruction. Most patients underwent anterolateral thigh (41 percent) or gracilis flap (40 percent) harvest. Eleven patients developed deep venous thromboses in one or more legs (9 percent): 10 of 11 (90.9 percent) in the donor extremity and five (45.5 percent) contralaterally (p = 0.022). Patients who underwent flap harvest had a 10-fold higher odds of venous thromboembolism formation when compared to comorbidity-matched controls without flap reconstruction (OR, 10.64; 95 percent CI, 1.11 to 102.34; p = 0.041). CONCLUSIONS: The rate of venous thromboembolism is higher than previously appreciated for reconstructive procedures of the abdomen and/or perineum that use pedicled lower extremity flaps-particularly in the operative extremity. Additional research can clarify the role for further prophylaxis or screening. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Surgical "Safe Zone": Rapid Anatomical Identification of the Lesser Occipital Nerve.

BACKGROUND: Surgical intervention has established a vital role in the management of chronic headaches. The lesser occipital nerve (LON) is a common target in patients suffering from occipital neuralgia and is often resected as a first-line option. We endeavored to define the relationships of the LON in the posterolateral neck to facilitate its safe and rapid intraoperative identification. METHODS: Seven fresh cadavers (14 nerves) were dissected, and their relationships to the mastoid prominence and nearby spinal accessory nerve (SAN) and greater auricular nerve were noted. RESULTS: The distance from the mastoid to the emergence of the LON along the posterior sternocleidomastoid ranged from 36 to 51 mm (mean: 45.2 mm), with relative symmetry between the two nerves in the same cadaver. The SAN emerged an average of 54 mm from the mastoid prominence. CONCLUSION: Exploration for the LON should begin at a point 40 mm from the mastoid prominence along the posterior border of the sternocleidomastoid muscle. If the point of exit of the LON is not identified within 10 mm of this exposure, our dissection continues cranially along the posterior border of the sternocleidomastoid, anterior to the trapezius. In rare cases the nerve may pierce the fibers of the muscle and ascend directly on top of the muscle belly. By limiting the caudal extend of the dissection, we can avoid exposure of the SAN and minimize the risk of iatrogenic nerve injury.

Prepectoral Versus Subpectoral Tissue Expander Placement: A Clinical and Quality of Life Outcomes Study.

BACKGROUND: Traditionally, tissue expanders (TEs) for breast reconstruction have been placed beneath the pectoralis major muscle with or without acellular dermal matrix. More recently, full acellular dermal matrix coverage has been described for prepectoral TE placement. Our study aims to explore differences in clinical and quality-of-life (QOL) outcomes for prepectoral versus subpectoral TE breast reconstruction. METHODS: We identified patients who underwent postmastectomy breast reconstruction with prepectoral or subpectoral TE placement between 2011 and 2015 and completed QOL surveys. Primary outcomes were postoperative pain and QOL scores. Secondary outcomes were clinical outcomes. We used Wilcoxon rank-sum test, chi-square test, and linear regression to compare outcomes. Postoperative follow-up for each patient was at least 60 days, except that of pain scores, which were at least 30 days. Mean age was 49 ± 10 years. RESULTS: Twenty-six prepectoral TE patients and 109 subpectoral TE patients met inclusion criteria. Pain scores were significantly lower at 12 hours, 1 day, 7 days, and 30 days postoperatively for the prepectoral group, compared with the subpectoral group, even after adjusting for confounding variables [PO12H: Sub-Pectoral (SP) median (interquartile range), 7 (5-8), Pre-Pectoral (PP), 5 (2.5-7.5), P value = 0.004; PO1D: SP, 5 (4-6), PP 3 (2-4), P value = < 0.001; PO7D: SP, 2 (0-4), PP, 0 (0-2), P value = 0.004; PO30D: SP, 0 (0-2), PP, 0 (0-0), P value = 0.039)]. Breast-Q scores were not significantly different between study groups. RAND-36 Physical Health scores were lower among prepectoral TE patients. CONCLUSIONS: Prepectoral TE breast reconstruction presents an opportunity to improve upon current reconstructive methods and does result in significantly lower pain scores. The associated risks have yet to be fully described and are important considerations, as these prepectoral patients had lower physical health outcome scores.

Vascularized Bone Grafting for Reconstruction of Oncologic Defects in the Spine: A Systematic Review and Pooled Analysis of the Literature.

BACKGROUND: Resection of primary spinal tumors requires reconstruction for restoration of spinal column stability. Traditionally, some combination of bone grafting and instrumentation is implemented. However, delayed healing environments are associated with pseudoarthrodesis and failure. Implementation of vascularized bone grafting (VBG) to complement hardware may present a solution. We evaluated the use of VBG in oncologic spinal reconstruction via systematic review and pooled analysis of literature. METHODS: We searched PubMed/MEDLINE, Embase, Cochrane, and Scopus for studies published through September 2017 according to the PRISMA guidelines and performed a pooled analysis of studies with n > 5. Additionally, we performed retrospective review of patients at the Johns Hopkins Hospital that received spinal reconstruction with VBG. RESULTS: We identified 21 eligible studies and executed a pooled analysis of 12. Analysis indicated an 89% (95% confidence interval [CI]: 0.75-1.03) rate of successful union when VBG is employed after primary tumor resection. The overall complication rate was 42% (95% CI: 0.23-0.61) and reoperation rate was 27% (95% CI: 0.12-0.41) in the pooled cohort. Wound complication rate was 18% (95% CI: 0.11-0.26). Fifteen out of 209 patients (7.2%) had instrumentation failure and mean time-to-union was 6 months. Consensus in the literature and in the patients reviewed is that introduction of VBG into irradiated or infected tissue beds proves advantageous given decreased resorption, increased load bearing, and faster consolidation. Downsides to this technique included longer operations, donor-site morbidity, and difficulty in coordinating care. CONCLUSIONS: Our results demonstrate that complication rates using VBG are similar to those reported in studies using non-VBG for similar spinal reconstructions; however, fusion rates are better. Given rapid fusion and possible hardware independence, VBG may be useful in reconstructing defects in patients with longer life expectancies and/or with a history of chemoradiation and/or infection at the site of tumor resection.

The Scleroderma Hand: Manifestations of Disease and Approach to Management.

Scleroderma is a rare autoimmune connective tissue disorder that often affects the hands. Manifestations in the hands include calcium deposits within the soft tissues that cause pain and may ulcerate through the skin, digital ischemia resulting in chronic wounds and digital gangrene, and joint contracture. Because of the underlying disease, patients with scleroderma have poorly vascularized tissue and a deficient soft tissue envelope, which make surgery particularly challenging. However, when undertaken with care, surgical intervention is often the best option for addressing the disabling hand conditions that so often accompany this disease.

Risk factors for wound-related reoperations in patients with metastatic spine tumor.

OBJECTIVE Resection of metastatic spine tumors can improve patients' quality of life by addressing pain or neurological compromise. However, resections are often complicated by wound dehiscence, infection, instrumentation failures, and the need for reoperation. Moreover, when reoperations are needed, the most common indication is surgical site infection and wound breakdown. In turn, wound reoperations increase morbidity as well as the length and cost of hospitalization. The aim of this study was to examine perioperative risk factors associated with increased rate of wound reoperations after metastatic spine tumor resection. METHODS A retrospective study of patients at a single institution who underwent metastatic spine tumor resection between 2003 and 2013 was conducted. Factors with a p value < 0.200 in a univariate analysis were included in the multivariate model. RESULTS A total of 159 patients were included in this study. Karnofsky Performance Scale score > 70, smoking status, hypertension, thromboembolic events, hyperlipidemia, increasing number of vertebral levels, and posterior approach were included in the multivariate analysis. Thromboembolic events (95% CI 1.19-48.5, p = 0.032) and number of levels involved were independently associated with increased wound reoperation rates in the multivariate model. For each additional spinal level involved, the risk for wound reoperations increased by 21% (95% CI 1.03-1.43, p = 0.018). CONCLUSIONS Although wound complications and subsequent reoperations are potential risks for all patients with metastatic spine tumor, due to adjuvant radiotherapy and other medical comorbidities, this study identified patients with thromboembolic events or those requiring a larger incision as being at the highest risk. Measures intended to decrease the occurrence of perioperative venous thromboembolism and to improve wound care, especially for long incisions, may decrease wound-related revision surgeries in this vulnerable group of patients.

Surgical Factors Associated with Prolonged Hospitalization after Reconstruction for Oncological Spine Surgery.

BACKGROUND: Posterior trunk reconstruction is increasingly possible as a result of advances in spinal instrumentation, reconstructive approaches, and perioperative critical care. Extensive cases often require a muscle flap or complex closure to obliterate dead space. Postsurgical wound complications and subsequent reoperations can lead to neural injury, higher hospital costs, and longer hospitalizations. We aim to identify risk factors that are associated with increased length of stay (LOS) for patients receiving flaps to close a spinal defect. METHODS: A single institution, retrospective cohort study was performed on all patients from 2002 to 2014 who received a muscle flap to close a spine defect. Medical and perioperative variables that were significantly associated with LOS (P < 0.05) in univariate analysis were included in a stepwise regression model. RESULTS: A total of 288 cases were identified. Presence of instrumentation, preoperative chemotherapy, wound dehiscence, cerebrospinal fluid leak, partial/total flap loss, and medical morbidity occurrence were all independently associated with increased LOS in a combined multivariate model (P < 0.02 for each of the 6 variables). Importantly, Kaplan-Meier analysis demonstrated that postoperative wound dehiscence increased LOS by 12 days. CONCLUSIONS: Spinal tumor resections often create large cavitary defects that necessitate the use of muscle flaps for closure. Patients who have received adjuvant chemotherapy require instrumentation, or those who develop specific wound-related or medical complications are at increased risk for prolonged hospitalization after spinal reconstruction. Thus, implementing measures to mitigate the occurrence of these adverse events will reduce costs and decrease the length of hospitalization.

Systematic Review of the Surgical Treatment of Extremity Lymphedema.

Background Although conservative management of lymphedema remains the first-line approach, surgery is effective in select patients. The purpose of this study was to review the literature and develop a treatment algorithm based on the highest quality lymphedema research. Methods A systematic literature review was performed to examine the surgical treatments for lymphedema. Studies were categorized into five groups describing excision, liposuction, lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and combined/multiple approaches. Studies were scored for methodological quality using the methodological index for nonrandomized studies (MINORS) scoring system. Results A total of 69 articles met inclusion criteria and were assigned MINORS scores with a maximum score of 16 or 24 for noncomparative or comparative studies, respectively. The average MINORS scores using noncomparative criteria were 12.1 for excision, 13.2 for liposuction, 12.6 for LVA, 13.1 for VLNT, and 13.5 for combined/multiple approaches. Loss to follow-up was the most common cause of low scores. Thirty-nine studies scoring > 12/16 or > 19/24 were considered high quality. In studies measuring excess volume reduction, the mean reduction was 96.6% (95% confidence interval [CI]: 86.2-107%) for liposuction, 33.1% (95% CI: 14.4-51.9%) for LVA, and 26.4% (95% CI: - 7.98 to 60.8%) for VLNT. Included excision articles did not report excess volume reduction. Conclusion Although the overall quality of lymphedema literature is fair, the MINORS scoring system is an effective method to isolate high-quality studies. These studies were used to develop an evidence-based algorithm to guide clinical practice. Further studies with a particular focus on patient follow-up will improve the validity of lymphedema surgery research.

Efficacy of Monitoring Devices in Support of Prevention of Pressure Injuries: Systematic Review and Meta-analysis.

GENERAL PURPOSE: To present a systematic review of the literature assessing the efficacy of monitoring devices for reducing the risk of developing pressure injuries. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Explain the methodology of the literature review and its results.2. Discuss the scope of the problem and the implications of the research. ABSTRACT: OBJECTIVE: To assess the efficacy of monitoring devices for reducing the risk of developing pressure injuries (PIs). DATA SOURCES: The authors systematically reviewed the literature by searching PubMed/MEDLINE and CINAHL databases through January 2016. STUDY SELECTION: Articles included clinical trials and cohort studies that tested monitoring devices, evaluating PI risk factors on patients in acute and skilled nursing settings. The articles were scored using the Methodological Index for Non-randomized Studies. DATA EXTRACTION: Using a standardized extraction form, the authors extracted patient inclusion/exclusion criteria, care setting, key baseline, description of monitoring device and methodology, number of patients included in each group, description of any standard of care, follow-up period, and outcomes. DATA SYNTHESIS: Of the identified 1866 publications, 9 met the inclusion criteria. The high-quality studies averaged Methodological Index for Non-randomized Studies scores of 19.4 for clinical trials and 12.2 for observational studies. These studies evaluated monitoring devices that measured interface pressure, subdermal tissue stress, motion, and moisture. Most studies found a statistically significant decrease in PIs; 2 studies were eligible for meta-analysis, demonstrating that use of monitoring devices was associated with an 88% reduction in the risk of developing PIs (Mantel-Haenszel risk ratio, 0.12; 95% confidence interval, 0.04-0.41; I = 0%). CONCLUSIONS: Pressure injury monitoring devices are associated with a strong reduction in the risk of developing PIs. These devices provide clinicians and patients with critical information to implement prevention guidelines. Randomized controlled trials would help assess which technologies are most effective at reducing the risk of developing PIs.