Shock Wave Therapy in Plastic Surgery: A Review of the Current Indications.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) represents a promising, non-invasive management strategy supporting the treatment of a variety of conditions related to plastic surgery. OBJECTIVES: This literature review aimed to give a systematic overview of current applications, its mechanism of action, and its potential to provide tangible therapies in plastic surgery. METHODS: The databases PubMed (National Institute of Health, Bethesda, MD), Embase (via Ovid [Elsevier, Amsterdam, the Netherlands]), and the Cochrane Library (Cochrane, London, UK) were searched for articles published up to June 1, 2021. Clinical studies of any design including ESWT in the context of plastic surgery were included. Two reviewers extracted data, and 46 articles were analyzed after application of the inclusion and exclusion criteria. RESULTS: Forty-six included studies (n = 1496) were categorized into the following broad themes: cellulite/body contouring/skin rejuvenation, burns/scar treatment, diabetic foot ulcers/chronic wound, and future perspectives of ESWT. Overall, applications of ESWT were heterogenous, and the majority of studies reported effectiveness of ESWT as an alternative treatment technique. Flawed methodology and differences in technical standards limit the outcome and conclusion of this review. CONCLUSIONS: There is yet insufficient evidence to support the effectiveness of any specific intervention included in this review; however, all included studies reported improvements in key outcomes. Where reported, ESWT displayed a good safety profile with no serious adverse events. Further research is needed to provide more evidence to delineate the indications of ESWT in plastic surgery.

Do frailty scores predict outcome after proximal femoral replacement for musculoskeletal tumours: a case series?

PURPOSE: Frailty has a negative independent relationship with morbidity and mortality. A frail individual has low resilience and adaptive capacity to stressors with unfavourable consequences. The relationship between musculoskeletal tumour patients undergoing surgery and frailty is underrepresented in literature. This study's questions are; what is the prevalence of frailty in patients undergoing surgery for musculoskeletal tumours; what is the correlation between frailty and survival plus secondary outcome measures including length of hospital stay (LOS); can clinicians use frailty scoring to support preoperative decision-making? METHODS: Patients over 60 years of age undergoing proximal femoral replacement for musculoskeletal tumours were included and classified as fit, vulnerable or frail using the modified frailty index (mFI), Rockwood and American Society of Anaesthesiologist's physical status classification (ASA) grading systems. Correlation with outcomes including survival and (LOS) was determined. RESULTS: 85 patients were identified of mean age 72.6 years. Median follow-up was 18.9 months. The prevalence of frailty ranged between 55 to 76% and the overall median survival in frail groups were 19.8 months with all scoring systems used. Frail patients classified by the Rockwood score had a greater LOS and a trend to reduced survival. CONCLUSIONS: There is a high prevalence of frailty in this cohort and frailty scores should be considered when planning surgery as part of holistic care. Moreover, a median survival greater than 18 months in frail patients supports the decision to offer surgery which may positively impact quality of life. Further research to identify the relationship between frailty and outcomes in musculoskeletal tumour patients is needed. LEVEL OF EVIDENCE: IV, Retrospective Case Series.

Extra-abdominal desmoid tumor fibromatosis: a multicenter EMSOS study.

BACKGROUND: Extra-abdominal desmoid tumor fibromatosis (DTF) is a rare, locally aggressive soft tissue tumour. The best treatment modality for this patient cohort is still object of debate. QUESTIONS/PURPOSE: This paper aimed to (1) to compare the outcomes of DTF after different treatment modalities, (2) to assess prognostic factors for recurrence following surgical excision, and (3) to assess prognostic factors for progression during observation. METHODS: This was a retrospective multicenter study under the patronage of the European Musculoskeletal Oncology Society (EMSOS). All seven centres involved were tertiary referral centres for soft tissue tumours. Baseline demographic data was collected for all patients as well as data on the diagnosis, tumour characteristics, clinical features, treatment modalities and whether they had any predisposing factors for DTF. RESULTS: Three hundred eighty-eight patients (240 female, 140 male) with a mean age of 37.6 (±18.8 SD, range: 3-85) were included in the study. Two hundred fifty-seven patients (66%) underwent surgical excision of ADF, 70 patients (18%) were observed without therapy, the residual patients had different conservative treatments. There were no significant differences in terms of tumour recurrence or progression between the different treatment groups. After surgical excision, younger age, recurrent disease and larger tumour size were risk factors for recurrence, while tumours around the shoulder girdle and painful lesions were at risk of progression in the observational group. CONCLUSION: Local recurrence rate after surgery was similar to progression rates under observation. Hence, observation in DTF seems to be justified, considering surgery in case of dimensional progression in 2 consecutive controls (3 and 6 months) and in painful lesions, with particular attention to lesions around the shoulder girdle.

The treatment of symptomatic fat necrosis: A review and introduction of a new treatment algorithm.

OBJECTIVE: Fat necrosis (FN) is a well-known complication in plastic surgery. Excision of symptomatic FN has been the gold standard, but it often results in contour irregularities that require subsequent treatment. Different alternative surgical and nonsurgical management strategies have been described; however, there are currently no guidelines. This literature review aims to provide an overview of available treatment options and current management standards to support clinical decision making. METHOD: A literature search in the databases PubMed, Embase (via Ovid), and Web Of Science was carried out to identify eligible articles. The search strategy included combinations of the following terms: "Fat necrosis "AND (treatment OR management OR therapy). Six articles discussing or reporting management strategies of FN in a plastic surgery context were included. RESULTS: A variety of techniques were used to manage symptomatic FN. Asymptomatic or small lesions can be treated conservatively. Oil cyst and moderately sized areas of symptomatic FN can effectively be treated by aspiration, ultrasound-assisted liposuction, or needle aeration. Calcified and large areas of FN require excision and debridement of necrotic fat tissue CONCLUSION: At present, there is no consensus on the management of symptomatic FN. The authors propose a new classification system to aid the guidance of management of symptomatic FN.

Ectopic extramammary Paget's disease of the abdominal wall with abdominoplasty reconstruction.

Ectopic extramammary Paget's disease describes an exceedingly rare intraepithelial adenocarcinoma arising within non-apocrine tissues. We present a case report of E-EPMD arising on the lower abdomen without underlying secondary malignancy in a 56-year-old female patient. We performed a wide local excision of the lesion with subsequent mini abdominoplasty reconstruction.

Pelvic Ewing sarcoma: Should all patients receive pre-operative radiotherapy, or should it be delivered selectively?

BACKGROUND: Locally recurrent disease following surgical resection of Ewing sarcoma (ES) confers a poor prognosis. Limited evidence is available evaluating non-selective use of pre-operative radiotherapy (RT) for patients with pelvic ES and its effect on local control and survival. PATIENTS AND METHODS: 49 consecutive patients with pelvic ES were identified retrospectively from a prospectively collated database. Patients either received non-selective pre-operative RT and surgery (n = 27), or selective post-operative RT (n = 22) (surgery alone (n = 11) or surgery and post-operative RT (n = 11)). RESULTS: Patients who had non-selective pre-operative radiotherapy appeared to have a higher LRFS, 88.0% compared to 66.5% in the selective RT group (p = 0.096, Kaplan Meier; p = 0.028, Chi-squared). Administration of non-selective, pre-operative RT to all patients with pelvic ES elevates the LFRS to that of the good responder group (≥90% tumour necrosis and margins, p = 0.880). There was no difference in metastasis-free survival, 60.0% and 54.5% (p = 0.728) and overall survival (OS), 57.7% and 63.6% (p = 0.893). The majority of pre-operative RT patients had both good necrosis (≥90%) (p = 0.003) and widely excised tumours, 81.5% vs 59.1% (p = 0.080). Tumour volume ≥250 ml was associated with worse LRFS (p = 0.045) and post-operative complications (p = 0.017). There may be improved LRFS (p = 0.057) with pre-operative proton-beam RT compared to surgery and selective post-operative RT. CONCLUSION: Pre-operative photon or proton-beam RT to all pelvic ES may improve LRFS compared to the selective delivery of post-operative RT. Radiotherapy delivered to all patients results in a greater percentage of highly necrotic tumours at surgical excision, enabling a greater proportion of patients with wide resection margins.

Implementation of research evidence in orthopaedics: a tale of three trials.

OBJECTIVE: To examine implementation of evidence in orthopaedic practice following publication of the results of three pivotal clinical trials. DESIGN: Case studies based on three orthopaedic trials funded in sequence by the National Institute for Health Research Health Technology Assessment (HTA) programme. These trials dealt with treatment of fractures of the humerus, radius and ankle, respectively. For each case study, we conducted time-series analyses to examine the relationship between publication of findings and the implementation (or not) of the findings. RESULTS: The results of all three trials favoured the less expensive and less invasive option. In two cases, a change of practice, in line with the evidence that eventually emerged, preceded publication. Furthermore, the upturn in use of the intervention most supported by each of these two trials corresponded to the start of recruitment to the respective trial. The remaining trial failed to influence practice despite yielding clear-cut evidence. CONCLUSIONS: Implementation of results of all three HTA orthopaedic trials favoured the less expensive and less invasive option. In two of the three studies, a change in practice, in line with the evidence that eventually emerged, preceded publication of that evidence. A trend or a change in practice, at around the start of the trial, indicates that the direction of causation opposes our hypothesis that publication of trial findings would lead to changes in practice. Our results provide provocative insight into the nuanced topic of research and practice, but further qualitative work is needed to fully explain what led to the pre-emptive change in practice we observed and why there was no change in the third case.

Dr Jerome Pierce Webster (1888-1974): Surgeon, historian, campaigner, and 'the father of plastic surgery education'.

Dr Jerome Pierce Webster is best remembered as the 'founder of plastic surgery education in the United States' on the basis of developing his nation's first plastic surgery residency programme, his role in the founding of the American Board of Plastic Surgery, and, more generally, his influence in professionalising this subspecialty. He also deserves to be remembered for his extensive missionary work in China, his publications as a successful bibliographer, and as an accomplished historian.