Influence of psychological factors on patient-reported upper extremity disability.

Disability reflects physical impairment and the influence of psychosocial factors. We investigated the relationship between disability and psychosocial factors in patients with upper extremity pathology. Ninety-two patients at a hand clinic were evaluated to assess disability, pain intensity, health status and psychosocial factors (pain catastrophizing, depression). Statistical analyses evaluated the relationships among disability and patient and psychosocial factors. Moderate levels of disability from all types of pathology were reported and associated with pain catastrophizing, pain and depression. Health status Short Form 36 domains were not correlated with disability as determined by Disabilities of the Arm, Shoulder and Hand (DASH) scores. A strong correlation was found between DASH and QuickDASH scores, but the QuickDASH scored significantly higher by 4 points. Pain catastrophizing was the strongest predictor of disability and explained 59% and 63% of variation in disability scores. Independent of pathology, those patients experiencing psychosocial issues, as well as demographic factors (i.e. employment status and age), were more likely to have disability with hand conditions and surgical procedures. We conclude from this study that psychological factors affect patient-reported outcomes. Level of evidence: IV.

The development of a treatment pathway for dermal regenerative matrix (DRM).

The process of standardising burn care and creating protocols within burn centres has, at its core, evidence-based practice principles combined with the clinical experiences of burn care specialists. Although protocols and pathways have been created for certain topics of burn care, they tend to be tailored to the local individual needs of each burn centre, which is a limiting factor for consideration of larger/nationwide approaches. In order to continue to improve the short and long term outcomes after burn injuries, such as increasing the survival rate, reduction in the incidence of sepsis and organ failure, and improving wound healing and scarring, more generalised care pathways combining the recommendations of a nationwide working group of burn care specialists should be created around the topics of interest to ultimately improve patients' outcomes. We describe the steps put in place in Canada to design and adopt a nationwide protocol from a single burn centre on the topic of wound healing and dermal substitutes as the initial exemplary process. This report summarizes the Canadian experience for this type of initiative, which can be used as framework for developing additional guidelines/protocols in other relevant burn care related topics in Canada or other countries.

Teaching Palatoplasty Using a High-Fidelity Cleft Palate Simulator.

BACKGROUND: Cleft palate repair is a challenging procedure for cleft surgeons to teach. A novel high-fidelity cleft palate simulator has been described for surgeon training. This study evaluates the simulator's effect on surgeon procedural confidence and palatoplasty knowledge among learners. METHODS: Plastic surgery trainees attended a palatoplasty workshop consisting of a didactic session on cleft palate anatomy and repair followed by a simulation session. Participants completed a procedural confidence questionnaire and palatoplasty knowledge test immediately before and after the workshop. RESULTS: All participants reported significantly higher procedural confidence following the workshop (p < 0.05). Those with cleft palate surgery experience had higher procedural confidence before (p < 0.001) and after (p < 0.001) the session. Palatoplasty knowledge test scores increased in 90 percent of participants. The mean baseline test score was 28 ± 10.89 percent and 43 ± 18.86 percent following the workshop. Those with prior cleft palate experience did not have higher mean baseline test scores than those with no experience (30 percent versus 28 percent; p > 0.05), but did have significantly higher scores after the workshop (61 percent versus 35 percent; p < 0.05). All trainees strongly agreed or agreed that the simulator should be integrated into training and they would use it again. CONCLUSIONS: This study demonstrates the effective use of a novel cleft palate simulator as a training tool to teach palatoplasty. Improved procedural confidence and knowledge were observed after a single session, with benefits seen among trainees both with and without previous cleft experience.

Virtual Surgical Planning Decreases Operative Time for Isolated Single Suture and Multi-suture Craniosynostosis Repair.

BACKGROUND: Cranial vault reconstruction is a complex procedure due to the need for precise 3-dimensional outcomes. Traditionally, the process involves manual bending of calvarial bone and plates. With the advent of virtual surgical planning (VSP), this procedure can be streamlined. Despite the advantages documented in the literature, there have been no case-control studies comparing VSP to traditional open cranial vault reconstruction. METHODS: Data were retrospectively collected on patients who underwent craniosynostosis repair during a 7-year period. Information was collected on patient demographics, intraoperative and postoperative factors, and intraoperative surgical time. High-resolution computed tomography scans were used for preoperative planning with engineers when designing osteotomies, bone flaps, and final positioning guides. RESULTS: A total of 66 patients underwent open craniosynostosis reconstruction between 2010 and 2017. There were 35 control (non-VSP) and 28 VSP cases. No difference in age, gender ratios, or number of prior operations was found. Blood loss was similar between the 2 groups. The VSP group had more screws and an increased length of postoperative hospital stay. The length of the operation was shorter in the VSP group for single suture and for multiple suture operations. Operative time decreased as the attending surgeon increased familiarity with the technique. CONCLUSIONS: VSP is a valuable tool for craniosynostosis repair. We found VSP decreases surgical time and allows for improved preoperative planning. Although there have been studies on VSP, this is the first large case-control study to be performed on its use in cranial vault remodeling.

Transverse Slicing of the Sixth-Seventh Costal Cartilaginous Junction: A Novel Technique to Prevent Warping in Nasal Surgery.

BACKGROUND: Costal cartilage is an important reconstructive tissue for correcting nasal deformities. Warping of costal cartilage, a recognized complication, can lead to significant functional and aesthetic problems. The authors present a technique to prevent warping that involves transverse slicing of the sixth-seventh costal cartilaginous junction, that when sliced perpendicular to the long axis of the rib, provides multiple long, narrow, clinically useful grafts with balanced cross-sections. The aim was to measure differences in cartilage warp between this technique (TJS) and traditional carving techniques. METHODS: Costal cartilage was obtained from human subjects and cut to clinically relevant dimensions using a custom cutting jig. The sixth-seventh costal cartilaginous junction was sliced transversely leaving the outer surface intact. The adjacent sixth rib cartilage was carved concentrically and eccentrically. The samples were incubated and standardized serial photography was performed over time up to 4 weeks. Warp was quantified by measuring nonlinearity of the grafts using least-squares regression and compared between carving techniques. RESULTS: TJS grafts (n = 10) resulted in significantly less warp than both eccentrically (n = 3) and concentrically carved grafts (n = 3) (P < 0.0001). Warp was significantly higher with eccentric carving compared with concentric carving (P < 0.0001). Warp increased significantly with time for both eccentric (P = 0002) and concentric (P = 0.0007) techniques while TJS warp did not (P = 0.56). CONCLUSION: The technique of transverse slicing costal cartilage from the sixth-seventh junction minimizes warp compared with traditional carving methods providing ample grafts of adequate length and versatility for reconstructive requirements.

Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MS-TRAM breast reconstruction: a prospective cohort study of 45 patients.

INTRODUCTION: The transversus abdominis plane (TAP) block is a peripheral nerve block of T6-L1 intercostal nerves of the abdominal wall. The purpose of this study was to evaluate the usefulness of intermittent TAP blockade for the first two postoperative days following free muscle sparing-transverse rectus abdominis muscle (MS-TRAM) or deep inferior epigastric perforator (DIEP) flap reconstruction of the breast. Therapeutic--Level II evidence. MATERIAL AND METHODS: This prospective cohort consisted of 45 consecutive patients who underwent DIEP or MS-TRAM free-flap breast reconstruction. Intra-operatively, a multi-orifice epidural catheter was inserted under direct vision into the TAP. Ten millilitres of 0.25% bupivacaine was injected into each TAP catheter every 12 h until removal on day 3. The control group consisted of 80 consecutive patients who underwent free MS-TRAM or DIEP free-flap breast reconstructions by the same two surgeons without TAP block. Postoperatively, both groups had patient-controlled analgesia (PCA) and the primary outcome was intravenous (IV) PCA opioid consumption in the first 48 h. RESULTS: There were no complications associated with using TAP catheters. The 48-h PCA-delivered opioid requirement was significantly less (p<0.001) in the TAP block group (17.10±17.23 mg IV morphine equivalent) compared to the control group (48.44±39.53 mg). CONCLUSION: Intermittent delivery of bupivacaine through the TAP block significantly reduced postoperative parenteral opioid requirements following free MS-TRAM or DIEP flap reconstruction of the breast. This is the first report of the TAP block being inserted under direct vision to provide postoperative analgesia at the abdominal flap donor site following microsurgical breast reconstruction.