Automatic analysis of the scapholunate distance using 4DCT imaging: normal values in the healthy wrist.

AIM: Early diagnosis of scapholunate ligament (SLL) injuries is crucial to prevent progression to debilitating osteoarthritis. Four-Dimensional Computed Tomography (4DCT) is a promising dynamic imaging modality for assessing such injuries. Capitalizing on the known correlation between SLL injuries and an increased scapholunate distance (SLD), this study aims to develop a fully automatic approach to evaluate the SLD continuously during wrist motion and to apply it to a dataset of healthy wrists to establish reference values. MATERIALS AND METHODS: 50 healthy wrists were analysed in this study. All subjects performed radioulnar deviation (RUD), flexion-extension (FE), and clenching fist (CF) movements during 4DCT acquisition. A novel, automatic method was developed to continuously compute the SLD at five distinct locations within the scapholunate joint, encompassing a centre, volar, dorsal, proximal, and distal measurement. RESULTS: The developed algorithm successfully processed datasets from all subjects. Our results showed that the SLD remained below 2 mm and exhibited minimal changes (median ranges between 0.3 mm and 0.65 mm) during RUD and CF at all measured locations. During FE, the volar and dorsal SLD changed significantly, with median ranges of 0.90 and 1.27 mm, respectively. CONCLUSION: This study establishes a unique database of normal SLD values in healthy wrists during wrist motion. Our results indicate that, aside from RUD and CF, FE may also be important in assessing wrist kinematics. Given the labour-intensive and time-consuming nature of manual analysis of 4DCT images, the introduction of this automated algorithm enhances the clinical utility of 4DCT in diagnosing dynamic wrist injuries.

Changes in patient-reported satisfaction and quality-of-life 6 months after rhinoplasty.

BACKGROUND: Rhinoplasty is a challenging and demanding procedure in plastic surgery. Surgical success, patient satisfaction, and improved quality-of-life are important outcomes. OBJECTIVES: This study aimed to evaluate patient-reported satisfaction with appearance, treatment, and decision outcomes as well as quality-of-life after rhinoplasty using validated questionnaires. The role of patient demographics on outcomes was also studied. METHODS: Patients who underwent a primary rhinoplasty were selected for this cohort study. Patient-reported satisfaction with appearance, treatment, and decision as well as quality-of-life were evaluated with the Utrecht Questionnaire and FACE-Q at intake and 6 months postoperatively. RESULTS: Overall, 380 patients were included. Patients reported a more positive subjective perception of nasal appearance (VAS score) at 6 months post-surgery compared with preoperative scores (7.9 ± 1.6 vs 3.2 ± 1.4, p < 0.05). Furthermore, higher quality-of-life and body image scores were observed at 6 months postoperatively compared with preoperative scores (7.7 ± 3.5 vs 15.2 ± 4.4, p < 0.05). Patients reported high satisfaction with treatment outcome (70.3 ± 23.4) as well as with their decision to undergo surgery (75.9 ± 23.4) on a scale of 0-100 at 6 months postoperatively. Patients reached similar postoperative scores regardless of their intake scores. Patients ≥30 years and patients with a history of cosmetic surgery were less satisfied postoperatively. CONCLUSION: Despite differences in appearance satisfaction at intake, most patients showed greater satisfaction with appearance, treatment, and decision outcomes as well as quality-of-life 6 months postoperatively. However, older age and a history of cosmetic surgery influenced these outcomes negatively. These factors should be considered during preoperative management of outcome expectations.

The 6 month interim analysis of a randomized controlled trial assessing the quality of life in patients with breast cancer related lymphedema undergoing lymphaticovenous anastomosis vs. conservative therapy.

Breast cancer related lymphedema (BCRL) is a chronic condition with a detrimental impact on psychosocial and physical well-being. Lymphaticovenous anastomosis has shown promising results in alleviating physical symptoms and increasing quality of life in patients with BCRL. The aim of the study is to evaluate the effect on health related quality of life (HrQol) after LVA surgery versus conservative treatment in patients with BCRL. The study is a prospective, multicenter randomized controlled trial. Adult women with unilateral BCRL, with early stage lymphedema and viable lymphatic vessels were included. The primary outcome measure was HrQol measured by the lymphedema functioning disability and health (Lymph-ICF) questionnaire. The secondary outcomes were volume difference measured by the water displacement method; the Upper Extremity Lymphedema (UEL) index; and daily use of the compression garments after 3 and 6 months. For this interim analysis 46 patients per group were included. There was a significant improvement in the domains in physical and mental function in the Lymph-ICF questionnaire in the LVA group after 6 months, (- 16.46 ± 18.5, p < 0.05, - 10.12 ± 29.5, p < 0.05 respectively). However, there was no statistical difference in the total score of the Lymph-ICF after 6 months in both groups (LVA-group; - 8.57 ± 22.6, p > 0.05, CDT-group; - 2.65 ± 18.2, p < 0.05). Furthermore, there was no significant volume reduction in both groups (LVA-group: 20.04 ± 196.40, p = 0.497, CDT: 33.98 ± 189.87, p = 0.236). In the LVA group, 41% partially of completely stopped wearing the compression garments after six months whereas in the CDT group 0% discontinued to use of compression garments. LVA resulted in improvement of the domains physical and mental function of the Lymph-ICF. Limb volume did not significantly improve after 6 months. However, around 42% could completely or partially stopped with the use of compression garments in the LVA group. The current results are promising, however longer follow up is required to assess long term effect of LVA for secondary lymphedema. Clinical Trial Registration: NCT02790021 registered on 03/06/2016.

Automatic segmentation and labelling of wrist bones in four-dimensional computed tomography datasets via deep learning.

This study developed a deep learning model for fully automatic segmentation and labelling of wrist bones from four-dimensional computed tomography (4DCT) scans. This is a crucial step towards implementing 4DCT for diagnosing wrist ligament lesions, reducing time-consuming analysis of extensive data.

Hyperbaric oxygen therapy for local late radiation toxicity in breast cancer patients: A systematic review.

PURPOSE: This systematic review aims to provide an overview of the literature on the effect of hyperbaric oxygen therapy (HBOT) on symptoms of local late radiation toxicity (LRT) in patients treated for breast cancer. METHODS: A systematic search was performed in September 2021. All studies with a sample size of ≥10 patients reporting the effect of HBOT for symptoms of LRT after radiotherapy of the breast and/or chest wall were included. The ROBINS-I tool was used for critical appraisal of methodological quality. The toxicity outcomes pain, fibrosis, lymphedema, necrosis/skin problems, arm and shoulder mobility, and breast and arm symptoms were evaluated. RESULTS: Nine studies concerning a total of 1308 patients were included in this review. Except for one study, sample sizes were small. Most studies had inadequate methodology with a substantial risk of bias. Post-HBOT, a significant reduction of pain was observed in 4/5 studies, of fibrosis in 1/2 studies, and of lymphedema of the breast and/or arm in 4/7 studies. Skin problems of the breast were significantly reduced in 1/2 studies, arm- and shoulder mobility significantly improved in 2/2 studies, and breast- and arm symptoms were significantly reduced in one study. CONCLUSION: This systematic review indicates that HBOT might be useful for reducing symptoms of LRT in breast cancer patients, however evidence is limited. A randomized controlled trial in a larger cohort of patients including a combination of patient- and clinician-reported outcome measures would be valuable to assess the effect of HBOT on symptoms of LRT.

DIEP flap breast reconstruction combined with vascularized lymph node transfer for patients with breast cancer-related lymphedema.

INTRODUCTION: Lymphedema is a condition which heavily impacts patients QoL. For patients who desire autologous breast reconstruction, lymph nodes can be included in the Deep Inferior Epigastric Artery (DIEP) flap combining vascularized lymph node transfer and autologous breast reconstruction. MATERIAL AND METHODS: Patients who received autologous breast reconstruction with a DIEP flap in combination with vascularized lymph nodes were included in this study. Volume measurements pre and post-surgery were analyzed and surveys including two versions of the ULL-27 questionnaire to measure QoL before and after surgery were send. RESULTS: In total, 45 out of 64 patients returned the questionnaires. The average follow up was 51 months. The total ULL-27 score increased with 12.6 points on average (p = 0.00). The subdomain scores (physical, psychological and social) also significantly increased (p = 0.00). In addition 69% of patients were able to decrease physiotherapy, 63% of patients were able to decrease compression garment usage and the incidence of skin infections decreased in 6 patients out of 7 patients who had recurrent skin infections prior to surgery. The volume difference between the affected and the healthy arm did not significantly change (407 ml-406 ml, p = 0.988). CONCLUSIONS: Vascularized lymph node transfer in combination with DIEP flap breast reconstruction can cause a significant improvement on lymphedema related QoL, even when a volume difference decrease is absent. It can also decrease compression garment usage and reduce the need for physiotherapy. Future prospective studies should evaluate these findings and identify patients that benefit most from such procedures.

Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction.

BACKGROUND: Enhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction. MATERIALS EN METHODS: The effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications. RESULTS: 152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028). CONCLUSION: An enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.

Designing and utilizing 3D-printed skin incision guides during the first Dutch bilateral hand-arm transplantation.

OBJECTIVE: To preoperatively plan skin incision in the case of the first Dutch bilateral hand-arm transplantation. BACKGROUND: A bilateral hand-arm transplantation has been performed for the first time in the Netherlands in 2019. In the context of preparation for this surgical procedure, the optimal patient-specific skin flap was determined. Skin flaps should be properly matched between donor and recipient to ensure sufficient tissue for the approximation of skin over the tendon anastomosis, adequate distal tip perfusion, and esthetics. METHODS: Preoperatively, stereophotogrammetry was obtained from the upper extremities of the patient and a volunteer with similar body physique. Skin flap dimensions were determined for each extremity, which resulted in patient-specific incision patterns. Combining this digital information yielded practical skin incision guides for both the donor and acceptor arms. Finally, the computer-aided designs were 3D printed. RESULTS: The 3D prints were convenient to utilize in both shaping the donor flaps as in preparing the acceptor extremities, taking only a few seconds during precious ischemia time. There was sufficient skin flap perfusion, and the wound-healing followed an uncomplicated course. No corrections were made to the initial skin incisions. CONCLUSIONS: Three-dimensional printed templates were successfully utilized in the first Dutch bilateral hand-arm transplantation. We believe its usage increased time efficiency, improved the match of skin flaps in donor and recipient arms, and allowed us to control the amount of skin surplus without skin flap tip necrosis. In these procedures where time is of the essence, we believe preoperative planning is imperative for its success.

Pre-operative CT scan measurements for predicting complications in patients undergoing complex ventral hernia repair using the component separation technique.

BACKGROUND: The component separation technique (CST) is considered an excellent technique for complex ventral hernia repair. However, postoperative infectious complications and reherniation rates are significant. Risk factor analysis for postoperative complication and reherniation has focused mostly on patient history and co-morbidity and shows equivocal results. The use of abdominal morphometrics derived from CT scans to assist in risk assessment seems promising. The aim of this study is to determine the predictability of reherniation and surgical site infections (SSI) using pre-operative CT measurements. METHODS: Electronic patient records were searched for patients who underwent CST between 2000 and 2013 and had a pre-operative CT scan available. Visceral fat volume (VFV), subcutaneous fat volume (SFV), loss of domain (LOD), rectus thickness and width (RT, RW), abdominal volume, hernia sac volume, total fat volume (TFV), sagittal distance (SD) and waist circumference (WC) were measured or calculated. Relevant variables were entered in multivariate regression analysis to determine their effect on reherniation and SSI as separate outcomes. RESULTS: Sixty-five patients were included. VFV (p = 0.025, OR = 1.65) was a significant predictor regarding reherniation. Hernia sac volume (p = 0.020, OR = 2.10) and SFV per 1000 cm3 (p = 0.034, OR = 0.26) were significant predictors of SSI. CONCLUSION: Visceral fat volume, subcutaneous fat volume and hernia sac volume derived from CT scan measurements may be used to predict reherniation and SSI in patients undergoing complex ventral hernia repair using CST. These findings may aid in optimizing patient-tailored preoperative risk assessment.

The effect of postoperative closed incision negative pressure therapy on the incidence of donor site wound dehiscence in breast reconstruction patients: DEhiscence PREvention Study (DEPRES), pilot randomized controlled trial.

AIM: Wound dehiscence is a serious postoperative complication associated both with high morbidity and mortality. It has a significant rate of occurrence in breast reconstruction surgeries with a deep internal epigastric perforator (DIEP) and with a profunda artery perforator (PAP) flap. Risk factors for wound dehiscence include smoking, diabetes mellitus, chronic obstructive pulmonary disease, and obesity. The aim of this pilot study was to assess whether postoperative treatment with closed incision negative pressure therapy (ciNPT) decreases the incidence of donor site wound dehiscence in breast reconstruction patients. METHOD: Women undergoing a breast reconstruction with a DIEP or PAP flap were enrolled in a pilot randomized controlled trial and assigned treatment with either ciNPT or adhesive strips. The primary outcome was wound dehiscence upon follow-up after four weeks. Secondary outcomes that were evaluated included wound infection, pain, and allergy. There was no loss to follow-up. RESULTS: This pilot study included 51 women (n = 25 ciNPT, n = 26 adhesive strips). The two groups did not differ significantly in patients demographics or comorbidities. Wound dehiscence occurred in 11 patients (n = 2 ciNPT, n = 9 adhesive strips). This difference was statistically significant: p = 0.038. There were no statistically significant differences in secondary outcomes between the two groups. CONCLUSION: In this pilot study, postoperative treatment with ciNPT decreased the incidence of donor site wound dehiscence in breast reconstruction patients. Further research is ongoing by the same hospital. This trial was registered in the Netherlands Trial Register (NTR) under ID no. NTR5808.

The merits of decision modelling in the earliest stages of the IDEAL framework: An innovative case in DIEP flap breast reconstructions.

BACKGROUND: The IDEAL framework aims at improving the evidence base of available surgical innovations. However, the development of such innovations and collection of evidence is costly. Surgical innovation can provide more value for money if innovations are evaluated at an early stage, where evaluations can inform the decision whether to stop or to further develop an innovation. We illustrate how decision modelling can be readily adopted at the earliest stages (0-1) of the IDEAL framework, using an innovation in bilateral DIEP flap breast reconstruction as an example. METHODS: We quantified expected costs and quality-adjusted life years (QALYs) of the current treatment and compared them with an innovation aimed at reducing complications and surgery time. The maximum effect of eliminating all complications (headroom analysis) was explored. Moreover, three scenarios with varying complications and surgery time reductions were modelled. Furthermore, the maximum price of the innovation was estimated in a threshold analysis according to its impact and societal willingness to pay. RESULTS: The headroom analysis showed that when all complications associated with the current treatment are prevented, up to €889 per patient is saved. Scenario analysis showed cost savings between €256 and €828 per patient. When surgery time is reduced by 15 min and complications by 50%, the innovation will remain cost-effective at €671 per patient. CONCLUSION: In a field struggling with cost containment, decision modelling can help to separate promising innovations from costly failures at an early stage. In this example, decision modelling showed that it seems worthwhile to further develop the innovation.

An innovative method of planning and displaying flap volume in DIEP flap breast reconstructions.

BACKGROUND: Determining the ideal volume of the harvested flap to achieve symmetry in deep inferior epigastric artery perforator (DIEP) flap breast reconstructions is complex. With preoperative imaging techniques such as 3D stereophotogrammetry and computed tomography angiography (CTA) available nowadays, we can combine information to preoperatively plan the optimal flap volume to be harvested. In this proof-of-concept, we investigated whether projection of a virtual flap planning onto the patient's abdomen using a projection method could result in harvesting the correct flap volume. METHODS: In six patients (n = 9 breasts), 3D stereophotogrammetry and CTA data were combined from which a virtual flap planning was created comprising perforator locations, blood vessel trajectory and flap size. All projected perforators were verified with Doppler ultrasound. Intraoperative flap measurements were collected to validate the determined flap delineation volume. RESULTS: The measured breast volume using 3D stereophotogrammetry was 578 ± 127 cc; on CTA images, 527 ± 106 cc flap volumes were planned. The nine harvested flaps weighed 533 ± 109 g resulting in a planned versus harvested flap mean difference of 5 ± 27 g (flap density 1.0 g/ml). In 41 out of 42 projected perforator locations, a Doppler signal was audible. CONCLUSION: This proof-of-concept shows in small numbers that flap volumes can be included into a virtual DIEP flap planning, and transferring the virtual planning to the patient through a projection method results in harvesting approximately the same volume during surgery. In our opinion, this innovative approach is the first step in consequently achieving symmetric breast volumes in DIEP flap breast reconstructions.

Displaying inguinal lymph nodes before transplantation in a deep inferior epigastric perforator flap breast reconstruction using an innovative projection method.

INTRODUCTION: Lymphedema of the arm is a common postoperative complication as a result of breast cancer surgery. One of the surgical treatments comprises modification of a deep inferior epigastric perforator (DIEP) flap breast reconstruction to facilitate additional lymph node transplantation from the inguinal area. Using computed tomography angiography (CTA), the distribution of these lymph nodes can be assessed. A virtual planning based on this CTA created for the DIEP flap is presented, with the inguinal lymph nodes included, followed by preoperatively projecting this information on the patient's abdomen. METHODS: A total of 10 patients underwent the standard imaging protocol: A preoperative CTA to assess the vascular anatomy of the lower abdomen. A three-dimensional (3D) model of the blood vessels was produced, and the inguinal lymph nodes in this reconstruction were included. Preoperative projection of the 3D model onto the patients' abdomen and inguinal area was performed, followed by tracing of this image. Intraoperatively found lymph nodes were identified by touch and compared with the markings on the skin. RESULTS: In all 10 patients, all lymph nodes located preoperatively were found intraoperatively within a 1-cm radius of the marking on the skin; and these were more easily located by two operating surgeons. CONCLUSION: Virtual planning of lymph node transplantations in a deep inferior epigastric artery perforator flap breast reconstruction seems feasible and can be performed quickly. This additional visual support aids the surgeon in locating the lymph nodes in the inguinal area.

Preliminary results using a newly developed projection method to visualize vascular anatomy prior to DIEP flap breast reconstruction.

INTRODUCTION: In a deep inferior epigastric perforator (DIEP) flap breast reconstruction, computed tomography angiography (CTA) is currently considered as the gold standard in preoperative imaging for this procedure. Unidirectional Doppler ultrasound (US) is frequently used; however, this method does not distinguish the main axial vessels from perforator arteries at the height of the fascia, it has a limited penetration depth, and it cannot assess the branching patterns of the deep inferior arteries. A new method and system were developed, which consisted of a video projector preoperatively displaying the location and intramuscular course of the artery perforators and subcutaneous branching on the patient's abdomen. METHOD: All patients (n=9) underwent a standard protocol: a preoperative CTA was performed and the DIEPs were localized using a unidirectional Doppler probe. In addition, a three-dimensional (3D) reconstruction of the perforator locations based on CTA was projected on the abdomen of the patients. All projected perforator locations were assessed using a unidirectional Doppler probe. The intraoperative results were collected for comparison. RESULTS: A total of 88 locations were marked with the use of unidirectional Doppler and a total of 100 perforators were projected (p=0.38). In 98 out of 100 projected perforator locations, a Doppler signal was audible. The intraoperative results demonstrate that 19 out of 34 transplanted perforators were correctly identified with unidirectional Doppler (56.9%±31.4%), where the projection method properly revealed 29 locations (84.3%±25.8%) (p=0.030). CONCLUSION: The projection method is not only capable of providing more information and identifying more perforators used for transplantation than unidirectional Doppler probing but also more accurate in pointing out the corresponding perforator found intraoperatively.