Antibiotic Prophylaxis in Alloplastic Breast Reconstruction: Regimens and Outcomes.

PURPOSE: Surgical site infections (SSI) in prosthesis-based breast reconstruction can have a significant impact on patient outcome. Despite current CDC (Centers for Disease Control and Prevention) guidelines recommending 24 hours of postoperative antibiotics, various perioperative antimicrobial regimens are reported in the literature. Consensus on the optimal duration of antibiotics remains unclear. In this study, the aim is to compare the incidence of surgical site infections following different antibiotic durations in alloplastic breast reconstruction. METHODS: In this retrospective cohort study, all consecutive patients who underwent expander/implant-based breast reconstruction between January 2009 and December 2014 at a tertiary centre were included. Data on patient demographics, risk factors, operative time, choice and timing of antibiotic used before surgery, and the duration of postoperative antibiotic use were collected. The primary outcome, SSI, is defined according to CDC criteria. RESULTS: A total of 507 consecutive expander/implant-based cases were included. Minimum follow-up time was 1 year. The overall infection incidence was 14% (95% CI: 11%-17%), and the rate of subsequent explantation was 8%. Of the infected cases, 80% (45/56) received 1 week of postoperative antibiotic, while 20% (11/56) had a prolonged course of antibiotics (2-3 weeks; P = .003, odds ratio [OR] = 2.9; 95% CI: 1.4-5.8). Most infections were superficial (65%). Prior history of radiation treatment was identified as a risk factor for developing surgical site infection (P = .02). CONCLUSION: Overall infection rate and risk factors for infections are in keeping with current literature. Prescribing one week of postoperative antibiotic was found to be associated with a higher incidence of SSI compared to a more prolonged antibiotic regimen.

OBJECTIF: Les infections au site opératoire (ISO) des reconstructions mammaires avec prothèse peuvent avoir des conséquences importantes sur le pronostic de la patiente. Malgré les directives à jour des Centers for Disease Control and Prevention (CDC) recommandant la prise d'antibiotiques pendant 24 heures après l'opération, les publications font état de diverses posologies antimicrobiennes périopératoires. La durée consensuelle optimale de la prise d'antibiotiques n'est pas bien établie. Dans la présente étude, les chercheurs comparent l'incidence d'ISO après une reconstruction mammaire alloplastique en fonction de diverses durées d'antibiothérapie. MÉTHODOLOGIE: Toutes les patientes consécutives qui ont subi une reconstruction mammaire par expanseurs ou par implants entre janvier 2009 et décembre 2014 dans un centre de soins tertiaires ont participé à la présente étude rétrospective de cohorte. Les chercheurs ont colligé les données sur la démographie, les facteurs de risque, la durée de l'opération, le choix et le moment de l'antibiothérapie préopératoire ainsi que la durée de l'antibiothérapie postopératoire. Le résultat clinique primaire, les ISO, est défini d'après les critères des CDC. RÉSULTATS: Au total, 507 cas consécutifs d'expanseurs ou d'implants ont été inclus dans l'étude. Le suivi était d'une durée minimale d'un an. L'incidence globale d'infection s'élevait à 14 % (IC à 95 %, 11 % à 17 %) et le taux d'explantations subséquent, à 8 %. De plus, 80 % des cas d'infection (45 sur 56) avaient reçu une antibiothérapie postopératoire d'une semaine, et 20 % (11 sur 56), une antibiothérapie prolongée (de 2 à 3 semaines; p=0,003, rapport de cote=2,9; IC à 95 %, 1,4 à 5,8). La plupart des infections étaient superficielles (65 %). Une radiothérapie antérieure était considérée comme un facteur de risque d'ISO (p=0,02). CONCLUSION: Le taux et les facteurs de risque globaux d'infection sont conformes aux publications à ce jour. La prescription d'antibiotiques pendant une semaine après l'opération était associée à une plus forte incidence d'ISO qu'une antibiothérapie plus longue.

Surgical Repair of Triangular Fibrocartilage Complex Tears: A Systematic Review.

Objective This study systematically reviews the outcomes of surgical repair of triangular fibrocartilage complex (TFCC) tears. Existing surgical techniques include capsular sutures, suture anchors, and transosseous sutures. However, there is still no consensus as to which is the most reliable method for ulnar-sided peripheral and foveal TFCC tears. Methods A systematic review of MEDLINE and EMBASE was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The focus was on traumatic Palmer 1B ulna-sided tears. Twenty-seven studies were included, including three comparative cohort studies. Results There was improvement in all functional outcome measures after repair of TFCC tears. The outcomes following peripheral and foveal repairs were good overall: Mayo Modified Wrist Evaluation (MMWE) score of 80.1 and 85.1, Disabilities of the Arm, Shoulder and Hand (DASH) score of 15.7 and 15.8, grip strength of 80.3 and 92.7% (of the nonoperated hand), and pain intensity score of 2.1 and 1.7, respectively. For peripheral tears, transosseous suture technique achieved better outcomes compared with capsular sutures in terms of grip strength, pain, Patient-Rated Wrist Evaluation (PRWE), and DASH scores (grip 85.8 vs. 77.7%; pain 1.5 vs. 2.2; PRWE 11.6 vs. 15.8; DASH 14.4 vs. 16.1). For foveal tears, transosseous sutures achieved overall better functional outcomes compared with suture anchors (MMWE 85.4 vs. 84.9, DASH 10.9 vs. 20.6, pain score 1.3 vs. 2.1), but did report slightly lower grip strength than the group with suture anchors (90.2 vs. 96.2%). Arthroscopic techniques achieved overall better outcomes compared with open repair technique. Conclusion Current evidence demonstrates that TFCC repair achieves good clinical outcomes, with low complication rates. Level of Evidence This is a Level IV, therapeutic study.

Intraoperative SPY Reduces Post-mastectomy Skin Flap Complications: A Systematic Review and Meta-Analysis.

BACKGROUND: Indocyanine-green and laser-assisted fluorescence angiography, known as the SPY system, is a recently developed tool that has shown promise in assessing tissue perfusion. Its intraoperative use is becoming more common particularly in breast surgery. This systematic review aims to determine whether SPY technology can reduce postoperative complications related to tissue ischemia, specifically skin necrosis of the mastectomy native breast skin flaps. METHODS: A systematic review of the literature was performed based on the PRISMA guideline. All studies that involved use of the SPY system to assess perfusion of postmastectomy skin flaps from January 1, 1960, to March 1, 2018 were included. Postoperative complications, including mastectomy skin flap necrosis were extracted from the selected studies. The perfusion-related complication rates and unexpected reoperation rates across multiple studies were then reviewed. RESULTS: Five relevant articles were identified including 902 patients undergoing mastectomy and native breast flap reconstructive procedures. Groups that used indocyanine-green angiography had statistically less incidence of native breast skin flap necrosis and unexpected reoperations due to perfusion-related complications compared with groups that monitored flaps with only clinical observation (odds ratio 0.54 for skin necrosis, and 0.36 for reoperation). CONCLUSIONS: In this systematic review, the incidence of native breast skin flap necrosis and unexpected reoperations were found to be statistically lower in cases where SPY was used. However, more prospective studies are required to establish SPY angiography as an accurate and cost-effective tool for assessment of tissue perfusion.

Resolution of Diplopia in Late Repair of Enophthalmos Following Facial Trauma.

Posttraumatic enophthalmos due to isolated or complex orbital fractures can contribute to diplopia. Current evidence recommends early repair. However, little is known about the outcome of enophthalmos correction when repair occurs beyond 30 days after trauma. In this systematic review, the authors aim to evaluate the current evidence on functional outcomes after delayed repair of posttraumatic enophthalmos.Two independent assessors undertook a systematic review of the literature using multiple databases. The authors' inclusion criteria identified studies involving patients at least 14 years of age who had surgical correction of persistent enophthalmos 30 days after initial trauma. Each eligible paper was included after critical appraisal using validated guidelines. Data on preoperative and postoperative enophthalmos and diplopia in each study was extracted. The pattern of fracture was also noted.The authors' search for the medical databases yielded 1053 articles, of which 6 eligible papers were included. Meta-analysis was performed. In patients with complex injuries involving orbital and mid-facial fractures, diplopia resolution was calculated to be 53%, and enophthalmos was corrected in 83% of the patients. In patients with isolated orbital fractures, 53% had resolution of their diplopia, and enophthalmos was corrected in 88% of the patients.Enophthalmos can be corrected to within 2 mm of the contralateral eye in both the isolated and complex orbital fractures in patients who present 30 days or greater after injury. Based on the studies reviewed, there is less predictability in diplopia resolution.

Proximal Phalanx Osteoid Osteoma: A Case Report and Literature Review.

Osteoid osteoma is a rare clinical entity often mistaken for osteomyelitis, enchondroma, osteochondroma and other bony pathologies. Cardinal features include localized swelling and nocturnal pain often relieved by nonsteroidal antiinflammatory drugs. Definitive treatment requires surgical removal of the lesion by curettage or en bloc excision. The following case report details the diagnosis and management of a recurrent case of osteoid osteoma in a long finger proximal phalanx. Included with this case report is a literature review of osteoid osteomas on the hand and the anatomic distribution of 289 cases published in the last 30 years.

Enhancement of facial nerve motoneuron regeneration through cross-face nerve grafts by adding end-to-side sensory axons.

BACKGROUND: In unilateral facial palsy, cross-face nerve grafts are used for emotional facial reanimation. Facial nerve regeneration through the grafts takes several months, and the functional results are sometimes inadequate. Chronic denervation of the cross-face nerve graft results in incomplete nerve regeneration. The authors hypothesize that donor axons from regional sensory nerves will enhance facial motoneuron regeneration, improve axon regeneration, and improve the amplitude of facial muscle movement. METHODS: In the rat model, a 30-mm nerve graft (right common peroneal nerve) was used as a cross-face nerve graft. The graft was coapted to the proximal stump of the transected right buccal branch of the facial nerve and the distal stumps of the transected left buccal and marginal mandibular branches. In one group, sensory occipital nerves were coapted end-to-side to the cross-face nerve graft. Regeneration of green fluorescent protein-positive axons was imaged in vivo in transgenic Thy1-green fluorescent protein rats, in which all neurons express green fluorescence. After 16 weeks, retrograde labeling of regenerated neurons and histomorphometric analysis of myelinated axons was performed. Functional outcomes were assessed with video analysis of whisker motion. RESULTS: "Pathway protection" with sensory axons significantly enhanced motoneuron regeneration, as assessed by retrograde labeling, in vivo fluorescence imaging, and histomorphometry, and significantly improved whisker motion during video analysis. CONCLUSION: Sensory pathway protection of cross-face nerve grafts counteracts chronic denervation in nerve grafts and improves regeneration and functional outcomes.

Characterization of neuronal death and functional deficits following nerve injury during the early postnatal developmental period in rats.

In contrast to adult rat nerve injury models, neonatal sciatic nerve crush leads to massive motor and sensory neuron death. Death of these neurons results from both the loss of functional contact between the nerve terminals and their targets, and the inability of immature Schwann cells in the distal stump of the injured nerve to sustain regeneration. However, current dogma holds that little to no motoneuron death occurs in response to nerve crush at postnatal day 5 (P5). The purpose of the current study was to fully characterize the extent of motor and sensory neuronal death and functional recovery following sciatic nerve crush at mid-thigh level in rats at postnatal days 3-30 (P3-P30), and then compare this to adult injured animals. Following nerve crush at P3, motoneuron numbers were reduced to 35% of that of naïve uninjured animals. Animals in the P5 and P7 group also displayed statistically fewer motoneurons than naïve animals. Animals that were injured at P30 or earlier displayed statistically lower sensory neuron counts in the dorsal root ganglion than naïve controls. Surprisingly, complete behavioral recovery was observed exclusively in the P30 and adult injured groups. Similar results were observed in muscle twitch/tetanic force analysis, motor unit number estimation and wet muscle weights. Rats in both the P5 and P7 injury groups displayed significant neuronal death and impaired functional recovery following injury, challenging current dogma and suggesting that severe deficits persist following nerve injury during this early postnatal developmental period. These findings have important implications concerning the timing of neonatal nerve injury in rats.

The ErbB2 inhibitor Herceptin (Trastuzumab) promotes axonal outgrowth four weeks after acute nerve transection and repair.

Accumulating evidence suggests that neuregulin, a potent Schwann cell mitogen, and its receptor, ErbB2, have an important role in regulating peripheral nerve regeneration. We hypothesized that Herceptin (Trastuzumab), a monoclonal antibody that binds ErbB2, would disrupt ErbB2 signaling, allowing us to evaluate ErbB2's importance in peripheral nerve regeneration. In this study, the extent of peripheral motor and sensory nerve regeneration and distal axonal outgrowth was analyzed two and four weeks after common peroneal (CP) nerve injury in rats. Outcomes analyzed included neuron counts after retrograde labeling, histomorphometry, and protein analysis. The data analysis revealed that there was no impact of Herceptin administration on either the numbers of motor or sensory neurons that regenerated their axons but histomorphometry revealed that Herceptin significantly increased the number of regenerated axons in the distal repaired nerve after 4 weeks. Protein analysis with Western blotting revealed no difference in either expression levels of ErbB2 or the amount of activated, phosphorylated ErbB2 in injured nerves. In conclusion, administration of the ErbB2 receptor inhibitor after nerve transection and surgical repair did not alter the number of regenerating neurons but markedly increased the number of regenerated axons per neuron in the distal nerve stump. Enhanced axon outgrowth in the presence of this ErbB2 inhibitor indicates that ErbB2 signaling may limit the numbers of axons that are emitted from each regenerating neuron.

Long-term outcomes following lower extremity sarcoma resection and reconstruction with vascularized fibula flaps in children.

BACKGROUND: Limb salvage operations in patients with bony oncologic defects carry technical challenges and may require long recoveries. This study aimed to evaluate functional outcomes, donor-site morbidity, and complications in lower limb bony oncologic defects reconstructed with vascularized fibula flaps in children. METHODS: The authors performed a retrospective review of consecutive pediatric patients undergoing this procedure between 1994 and 2012. Data on operative details, functional outcomes, and complications were analyzed. A telephone survey was conducted to assess patient satisfaction and quality of life. RESULTS: Eighteen patients who underwent 19 reconstructions were included. Mean age at resection was 10 years (range, 1.5 to 17 years). No patients developed local recurrence, although two patients had metastatic lung nodules resected. All patients were alive at last review, with a mean follow-up of 57 months (range, 10 to 145 months). Flap survival was 95 percent. Median time to bony union was 24 months (range, 9 to 72 months). The fibula flap fracture rate was 52.6 percent. At the end of the study period, 72 percent of patients were fully weight-bearing, all school-age children had returned to full-time school, and 50 percent were involved in sports. Fifty-six percent of patients participated in the follow-up telephone survey; of these, 90 percent expressed satisfaction with the outcome of the surgery. CONCLUSIONS: This study demonstrates that the vascularized fibula flap is an excellent option for reconstruction of lower limb oncologic defects in children. Despite complications, long-term follow-up suggests that most children are able to lead active lifestyles. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A prospective study of pediatric hand fractures and review of the literature.

OBJECTIVE: Hand fractures represent a leading cause of morbidity in children. However, little information exists correlating the mechanisms and environment of injury with outcomes and treatments. We examine the demographics, etiology, anatomic location, mechanism, and management of pediatric hand fractures in our center's hand unit. METHODS: We conducted a prospective observational study on all children with acute hand fractures evaluated in the Plastic Surgery Emergency Clinic during a 3-month period in 2010. Data pertaining to demographics, referral patterns, injury pattern, clinical outcomes, and other factors related to hand fractures were then analyzed and interpreted. RESULTS: Most children were referred by our institution's emergency department. More than 60% were boys, and nearly half were between 10 and 15 years old. The right and left hands were injured at equal rates. Most of the injuries (90%) occurred in the afternoon or evening. More than 85% occurred in urban, rather than rural, environments. Crush injuries were the leading cause in toddlers, whereas sports-related injuries became the major cause of injury in older groups. Proximal phalanges were the most common bone injured, and the fifth digit was the most commonly injured digit. More than 80% of the fractures were managed nonsurgically. CONCLUSIONS: The pattern of pediatric hand fracture in different age groups is highlighted in this article. The observations from this study will hopefully encourage further review with a larger cohort and a focus on preventative measures for pediatric hand fractures.

Rat-derived processed nerve allografts support more axon regeneration in rat than human-derived processed nerve xenografts.

Processed nerve allografts are increasingly used as "off the shelf" nerve replacements for surgically bridging nerve gaps. Benchmarking the regenerative capacity of a commercially available human-derived nerve or xenograft in a rat nerve injury model would provide a convenient platform for future studies seeking to modify the processed nerve graft. Human and rat processed nerve grafts were used to bridge a 14 mm defect in a Sprague-Dawley rat sciatic nerve. Reversed autografts served as a positive control group. Twelve weeks following surgery, the distal nerve stumps were retrograde labeled and harvested for histology and histomorphometry. The cross-sectional areas of the human- and rat-derived processed nerve grafts were similar. Neuron counts and myelinated axon counts following use of the human-derived processed xenografts were decreased compared with those obtained from both the rat-derived processed nerve allografts and the autografts; the rat-derived processed nerve allografts were statistically equivalent to autografts. Measures of nerve fiber diameter and myelination revealed inferior axon regeneration maturity in both processed nerve grafts compared with autografts. Processed xenografts showed significantly reduced regeneration compared with autografts or processed allografts indicating that cross-species immunological reactions are important considerations in this rat model.

Functional recovery following peripheral nerve injury in the transgenic Thy1-GFP rat.

Transgenic mice have been previously used to assess nerve regeneration following peripheral nerve injury. However, mouse models are limited by their small caliber nerves, short nerve lengths, and their inability to fully participate during behavioral assessments. The transgenic Thy1 GFP rat is a novel transgenic rat model designed to assess regeneration following peripheral nerve injury. However, return of functional and behavioral recovery following nerve injury has not yet been evaluated in these rats. In this study, we ask whether differences in anatomy, recovery of locomotion, myological, and histomorphological measures exist between transgenic Thy1 GFP rats when compared to wild type (WT) Sprague Dawley rats following unilateral sciatic nerve injury. We found that both motor and sensory neuronal architecture, overground and skilled locomotion, muscle force, motor unit number estimation (MUNE) and wet muscle weights, and histomorphometric assessments are similar between both genetic phenotypes. Overall, these data support the use of the transgenic Thy1-GFP rat in experiments assessing functional and behavioral recovery following nerve injury and repair.

Functional motor recovery is improved due to local placement of GDNF microspheres after delayed nerve repair.

The majority of bioengineering strategies to promote peripheral nerve regeneration after injury have focused on therapies to bridge large nerve defects while fewer therapies are being developed to treat other nerve injuries, such as nerve transection. We constructed delivery systems using fibrin gels containing either free GDNF or polylactide-glycolic acid (PLGA) microspheres with GDNF to treat delayed nerve repair, where ELISA verified GDNF release. We determined the formulation of microspheres containing GDNF that optimized nerve regeneration and functional recovery in a rat model of delayed nerve repair. Experimental groups underwent delayed nerve repair and treatment with GDNF microspheres in fibrin glue at the repair site or control treatments (empty microspheres or free GDNF without microspheres). Contractile muscle force, muscle mass, and MUNE were measured 12 weeks following treatment, where GDNF microspheres (2 weeks formulation) were superior compared to either no GDNF or short-term release of free GDNF to nerve. Nerve histology distal to the repair site demonstrated increased axon counts and fiber diameters due to GDNF microspheres (2 weeks formulation). GDNF microspheres partially reversed the deleterious effects of chronic nerve injury, and recovery was slightly favored with the 2 weeks formulation compared to the 4 weeks formulation.

Esmodil: an acetylcholine mimetic resurfaces in a Southern Australian marine sponge Raspailia (Raspailia) sp.

Bioassay directed fractionation of a Raspailia (Raspailia) sp. (Order Poecilosclerida; Family Raspailiidae) collected during scientific trawling operations off the Northern Rottnest Shelf yielded as nematocidal agents the known metabolites, phorboxazoles A (1) and B (2). Further examination revealed the new natural product but known synthetic compound, esmodil (3). The structure for 3 was confirmed by spectroscopic analysis and total synthesis.