Using acoustic feedback and analyses for removal of bone cement during revision knee replacement surgeries.

PURPOSE: The purpose of this study was to analyze the scraping sounds generated during revision knee replacement surgeries to discriminate between the inner cortical bone and the cement, with the goal of minimizing bone removal and increasing the structural integrity of the revision. METHODS: We prepared seven porcine femurs by partially filling them with bone cement, and recorded scraping sounds produced by a surgical scraping tool. We used a hierarchical machine learning approach to first detect a contact and then classify it as either bone or cement. This approach was based on a Support Vector Machine learning algorithm that was fed with temporal and spectral features of the sounds. A Leave-One-Bone-Out validation method was used to assess the performance of the proposed method. RESULTS: The average recall for the noncontact, bone, and cement classes was 98%, 75%, and 72%, respectively. The corresponding precision for the respective classes was 99%, 67%, and 61%. CONCLUSION: The scraping sound that is generated during revision replacement surgeries carries significant information about the material that is being scraped. Such information can be extracted using a supervised machine learning algorithm. The scraping sound produced during revision replacement procedures can potentially be used to enhance cement removal during knee revision surgery. Future work will assess whether such monitoring can increase the structural integrity of the revision.

Citation Analysis in Breast Reconstruction Publications Between 2000 and 2010.

Introduction and Purpose: Breast reconstruction is an active area of plastic surgery research. Citation analysis allows for quantitative analysis of publications, with more citations presumed to indicate greater influence. We performed citation analysis to evaluate the most cited papers on breast reconstruction between 2000 to 2010 to identify contemporary research trends. Methods: The SCI-EXPANDED database was used to identify the 50 most cited papers. Data points included authorship, publication year, publication journal, study design, level of evidence, number of surgeons/institutions, center of surgery, primary outcome assessed, implant/flap/acellular dermal matrix/fat graft, acellular dermal matrix brand and use with implants/flaps, fat graft use with implants/flaps, unilateral/bilateral, one-/two-stage, immediate/delayed, number of patients/procedures, complications. Descriptive analysis of trends was performed based on results. Results: 20% of papers were published in 2006, 16% in 2007 and 12% in both 2004/2009. 66% were published in Plastic and Reconstructive Surgery. The majority were retrospective or case series, and of Level III or IV evidence. The one Level I study was a prospective multicenter trial. 21 and 7 papers discussed procedures by single/multiple surgeons, respectively. Results from single/multiple centers were discussed in 18 and 6 papers, respectively. 30 papers discussed implant-based reconstruction, 22 papers flap-based (19 microsurgical), 15 papers acellular dermal matrix, and five papers fat grafting. The primary focus in the majority was complications or outcomes. Conclusion: Our analysis demonstrates continually evolving techniques in breast reconstruction. However, there is notable lack of high quality evidence to guide surgical decision-making in the face of increasing surgical options.

Introduction et objectif: La reconstruction mammaire est un secteur actif de la recherche en chirurgie plastique. L'analyse de citations permet de procéder à une analyse quantitative des publications, un plus grand nombre de citations étant réputé indiquer une plus grande influence. Les chercheurs ont effectué une analyse de citations pour évaluer les articles les plus cités sur la reconstruction mammaire entre 2000 et 2010 et établir les tendances contemporaines de la recherche. Méthodologie: Les chercheurs ont utilisé la base de données SCI-EXPANDED pour extraire les 50 articles les plus cités. Les éléments de données incluaient les auteurs; l'année de publication; la revue; la méthodologie; la qualité des preuves; le nombre de chirurgiens et d'établissements, le centre chirurgical, l'évaluation des résultats primaires; l'implant, le lambeau, la matrice dermique acellulaire, la greffe de graisse; le type de matrice dermique acellulaire et son utilisation avec les implants et les lambeaux; l'utilisation de greffe de graisse avec les implants et les lambeaux; les reconstructions unilatérales ou bilatérales, en une ou deux phases, immédiates ou tardives; le nombre de patientes et d'interventions et les complications. Les chercheurs ont procédé à une analyse descriptive des tendances en fonction des résultats. Résultats: L'analyse a démontré que 20 % des articles ont été publiés en 2006, 16 % en 2007 et 12 % à la fois en 2004 et 2009. De plus, 66 % ont paru dans la revue Plastic and Reconstructive Surgery. La plupart étaient des études rétrospectives ou des séries de cas et contenaient des données probantes de niveau III ou IV. La seule étude de niveau I était un essai multicentrique prospectif. Par ailleurs, 21 articles ont traité d'interventions réalisées par un seul chirurgien, et sept, par de multiples chirurgiens. Les résultats monocentriques ont été abordés dans 18 articles, et les résultats multicentriques, dans six articles. Enfin, 30 articles portaient sur les reconstructions par implant, 22, sur les reconstructions par lambeau (dont 19 microchirurgies), 15, sur la matrice dermique acellulaire et cinq, sur les greffes de graisse. Les complications ou les résultats cliniques étaient l'objectif principal de la majorité des études. Conclusion: L'analyse a démontré que les techniques de reconstruction mammaire sont en constante évolution. Cependant, les données de qualité font défaut pour orienter les décisions chirurgicales à la lumière des possibilités chirurgicales croissantes.

Outcomes Following Gender Affirming Phalloplasty: A Systematic Review and Meta-Analysis.

INTRODUCTION: Phalloplasty is one of the genital genders affirming surgeries sought by transmasculine transgender patients during transition. Despite current advances in surgical techniques, the lack of consistency in outcomes evaluation for phalloplasty leads to significant challenges in guiding patients in clinical decision making. AIMS: This systematic review and meta-analysis aims to assess outcomes for different phalloplasty surgical techniques. METHODS: The literature was searched using Medical Literature Analysis and Retrieval System Online (MEDLINE; PubMed), Excerpta Medica database, and Cochrane Database of Systematic Reviews. All English-language randomized control trials, prospective and retrospective cohort studies, case series, and case reports of at least 4 patients were included. The primary outcome was postoperative complications, and the secondary outcomes were functional and aesthetic results. Proportional meta-analysis was used to pool complication rates using a random-effects model. RESULTS: Database searching generated 39 final articles, with 19 case series, 3 cross-sectional studies, and 17 retrospective cohort studies. A total of 1731 patients underwent phalloplasty, with the most common type of reconstruction performed being the radial forearm free flap (75.1%). Overall complication rate was high at 76.5%, of which urethral complications were high in all reconstructive subgroups (urethral fistula rate of 34.1% and urethral stricture rate of 25.4%). Postoperative functional outcomes were reported in 57.6% of patients, finding that most had tactile sensation (93.9%) and can void while standing (92.2%). Aesthetic outcomes were only reported in 6.3% of patients, with mean length achieved being 12.26 cm (SD = 0.81 cm) and mean circumference being 10.18 cm (SD = 3.69 cm). CONCLUSION: In the transmasculine transgender population, current evidence of the various phalloplasty surgical techniques and their expected postoperative outcomes is weak. Future research may consider developing a standardized core outcome set to improve clinical decision making. Wang AMQ, Tsang V, Mankowski P, et al. Outcomes Following Gender Affirming Phalloplasty: A Systematic Review and Meta-Analysis. Sex Med Rev 2022;10:499-512.

Resident Behaviours to Prioritize According to Canadian Plastic Surgeons.

INTRODUCTION: Many articles have been published outlining the resident selection process for plastic surgery training programs. However, which qualities Canadian plastic surgeons value most in their current residents remains unclear. A national survey study was conducted to identify which attributes surgeons associate with the highest resident performance and which behaviours trainees should prioritize during their training. METHODS: A literature review was performed to identify studies that documented attributes valued in plastic surgery applicants and characteristics of high-performing surgical residents. These qualities were extracted to construct a survey consisting of both ranking and open-ended questions. After an iterative review process, the survey was disseminated nationally to consultants and trainees of Canadian plastic surgery training programs. RESULTS: Survey responses were obtained from 120 invitees and a weighted rank was calculated for each evaluated attribute. The terms integrity, professional, and work ethic were viewed as the most important attributes prized by surgeons. Dishonesty, lack of dependability, and unprofessionalism were viewed as the most concerning behaviours. Additionally, disinterest and arrogance were identified by the open-ended questions as behaviours surgeons would like to see less frequently in their trainees. When compared to surgeons, trainees undervalued the importance of knowledge and the impact of unprofessional behaviour. CONCLUSIONS: With the multiple roles that a resident must fulfill, understanding which attributes are of the most importance will help focus self-directed learning and development within residency programs. Ultimately, instilling the importance of integrity and professionalism is most highly valued by members of the Canadian plastic surgery community.

Using Laser Range-finding to Measure Bore Depth in Surgical Drilling of Bone.

BACKGROUND: Measuring drilled bore depth in bone is an important part of osteosynthesis surgery. Current methods have substantial limitations in terms of reliability, leading to placement of incorrectly sized screws and unsatisfactory user experience. QUESTIONS/PURPOSES: (1) Can a prototype laser range-finder measure bore depth in bone as well as or better than a conventional depth gauge in terms of accuracy and precision (that is, variability)? METHODS: A conventional analog orthopaedic surgical depth gauge was compared with a laser range-finder-based prototype. Experiments were conducted on four pig hind limbs, with bicortical holes drilled in the femur and the tibia. Two surgeons alternated drilling bores in three different clinically relevant conditions: straight drilling through the diaphysis, angled drilling through the diaphysis, and straight drilling through the metaphysis. Depth measurements were taken with the laser range-finder-based prototype, and the conventional depth gauge and compared against depth measurements obtained from a CT image that served as the reference measurement. RESULTS: In straight diaphyseal drilling the laser range-finder-based prototype had a larger mean error of 1.34 mm (± 0.7 mm) compared with a mean error of -0.06 mm (± 1.38 mm) using the conventional gauge (95% CI 0.824 to 1.976; p < 0.001). In angled diaphyseal drilling, there was no difference in mean error between the laser range-finder-based prototype (1.66 ± 0.86 mm) and the conventional gauge (2.36 ± 3.79 mm [95% CI -2.338 to 0.938]; p = 0.393). In straight metaphyseal drilling, there was no difference in mean error between the laser range-finder-based prototype (2.11 ± 0.8 mm) and the conventional gauge (1.51 ± 3.19 mm [95% CI -0.500 to 1.700]; p = 0.280). The laser range-finder-based prototype had greater precision (smaller variance) than the conventional depth gauge in straight diaphyseal drilling (p < 0.001), angled diaphyseal drilling (p < 0.001), and straight metaphyseal drilling (p < 0.001). CONCLUSIONS: A laser range-finder-based prototype mounted on a conventional surgical drill demonstrated overall similar accuracy and better precision in measuring drilled bore depth in bone compared with the conventional depth gauge. CLINICAL RELEVANCE: A device based on this concept could improve the reliability of bore depth measurement in surgical practice and could therefore reduce the frequency of screw replacement and associated complications.

Improved outcomes of renal injury following burn trauma.

BACKGROUND: Acute kidney injury (AKI) is common in major burn injuries and associated with increased mortality. With advances in surgical and critical care it is unclear if mortality in this population remains this high. This study aims to describe incidence and outcomes of patients admitted to intensive care (ICU) with a burn injury who develop AKI. We additionally sought to determine risk factors for developing AKI. METHODS: A historical cohort study of patients admitted to ICU from 2010 to 2016 with major burn injury was conducted. Demographic, laboratory, and clinical information was collected. AKI was defined by Acute Kidney Injury Network (AKIN) classification. Multivariable logistic regression was used to model association between baseline risk factors and risk of AKI. RESULTS: Of the 151 patients included, 64 people developed AKI (42%) defined by stages 1-3 of AKIN criteria. The median TBSA was 20% (IQR 9-41). Renal replacement therapy was required in 18/64 (28%) who developed AKI. Multivariable logistic regression demonstrated association between AKI and the following variables: APACHE II score (OR 1.2, 95%CI 1.1-1.3, P = 0.001), age (OR 1.8 per 10-year increase, 95%CI: 1.2-2.5, P = 0.002) and log(TBSA). Fractional polynomial regression analysis demonstrates that the best functional form of TBSA was in the natural logarithm (OR 2.7, 95%CI: 1.5-4.7, p = 0.001). Compared to those without AKI, patients with AKI had longer duration of mechanical ventilation, (median 11 [IQR 6-19] vs. 4 [IQR 2-9] days), ICU stay (15 [IQR 9-22] vs. 6 [IQR 3-10] days), and increased mortality (14 of 64(22%) vs. 4 of 87(5%). CONCLUSIONS: AKI is common in patients with a major burn injury. However, mortality is lower than described in the literature, particularly for those who required renal replacement therapy.

Managing Opioid Addiction Risk in Plastic Surgery during the Perioperative Period.

Opioid addiction is a public health crisis that affects all areas of medicine. Large numbers of the population across all racial and economic demographics misuse prescription opioids and use illicit opioids. The current understanding is that opioid misuse is a disease that requires treatment, and is not an issue of choice or character. Use of opioid medication is a necessary part of postoperative analgesia, but many physicians are unsure of how to do this safely given the risk of patients developing an opioid misuse disorder. This review gives an update of the current state of the opioid crisis, explains how current surgeons' prescribing practices are contributing to it, and gives recommendations on how to use opioid medication safely in the perioperative period.

Cross-Face Nerve Grafting with Infraorbital Nerve Pathway Protection: Anatomic and Histomorphometric Feasibility Study.

Smiling is an important aspect of emotional expression and social interaction, leaving facial palsy patients with impaired social functioning and decreased overall quality of life. Although there are several techniques available for facial reanimation, staged facial reanimation using donor nerve branches from the contralateral, functioning facial nerve connected to a cross-face nerve graft (CFNG) is the only technique that can reliably reproduce an emotionally spontaneous smile. Although CFNGs provide spontaneity, they typically produce less smile excursion than when the subsequent free functioning muscle flap is innervated with the motor nerve to the masseter muscle. This may be explained in part by the larger number of donor motor axons when using the masseter nerve, as studies have shown that only 20% to 50% of facial nerve donor axons successfully cross the nerve graft to innervate their targets. As demonstrated in our animal studies, increasing the number of donor axons that grow into and traverse the CFNG to innervate the free muscle transfer increases muscle movement, and this phenomenon may provide patients with the benefit of improved smile excursion. We have previously shown in animal studies that sensory nerves, when coapted to a nerve graft, improve axonal growth through the nerve graft and improve muscle excursion. Here, we describe the feasibility of and our experience in translating these results clinically by coapting the distal portion of the CFNG to branches of the infraorbital nerve.

Acute hand and wrist injuries sustained during recreational mountain biking: a prospective study.

BACKGROUND: Recreational mountain biking continues to increase in popularity and is a significant source of traumatic injury, including injuries to the hand and wrist. METHODS: A prospective survey of all hand and wrist injuries sustained while participating in recreational mountain biking presenting to the emergency department at the Municipality of Whistler and the District of Squamish was conducted over a 12-month consecutive period. RESULTS: An analysis of 765 unique emergency department visits with 1,079 distinct injuries was performed. Of these injuries, 511 were sustained to the upper limb. Injury to the metacarpal and metacarpal phalangeal joints was the most common hand injury (52) followed by proximal phalanx and proximal interphalangeal joint (20). CONCLUSIONS: Mountain biking is a frequent source of a variety of upper limb trauma, and preventative efforts are necessary to minimize the burden of these injuries.

Atypical fibroxanthoma: clinicopathologic determinants for recurrence and implications for surgical management.

BACKGROUND AND OBJECTIVES: Atypical fibroxanthoma (AFX) is an uncommon skin tumor occurring primarily in the head and neck region of elderly Caucasian males. Treated with local excision, the disease is thought to be fairly benign but can occasionally demonstrate aggressive local recurrence as well as distant metastasis. METHODS: Seventy-one cases of AFX were reviewed, representing all patients presenting to the Health Sciences Centre of South Eastern Ontario with the diagnosis of AFX in the period 1989-2008. Demographic and pathologic data were obtained from patient charts for analysis. RESULTS: Mean age at presentation was 76, with a male:female ratio of 4:1. Recurrence occurred in 10 patients after an average period of 7.3 months. Three recurrent lesions went on to distant metastasis, on average 14.3 months after initial presentation. The remaining 60 tumors did not recur. Histologically, tumor extending beyond the dermis into the underlying adipose and muscular tissue had a 29.4% chance of local recurrence and an 11.8% chance of metastasis compared to lesions confined to the dermis only (9.3% and 1.8%). CONCLUSIONS: While the majority of AFX presentations are benign, there is a real possibility of metastatic spread. Invasion beyond the dermis and a rapid rate of recurrence are suggestive of a more aggressive clinical course.

Influence of Donor Tissue Factors on Detachment Rate in DSAEK Patients.

Purpose. To determine whether the rate of graft detachment in patients undergoing the DSAEK procedure is influenced by the time elapsed between donor death and tissue implantation. Methods. Data on procedure outcome and donor tissue for patients undergoing the DSAEK procedure were reviewed. Data on time elapsed between harvest, processing, storage, and implantation of the tissue, as well as donor tissue endothelial cell count were obtained from reports made available from the Eye Bank of Canada. The adverse outcome of interest was graft detachment. Results. 71 cases were reviewed, with 14% resulting in detachment. The following time periods were compared between detachment and nondetachment groups: donor death to enucleation; enucleation to processing; duration of storage at the Eye Bank to implantation. No statistically significant differences were found (Student's t-test, P > 0.05). Endothelial cell counts of donor tissue were compared between the two groups, and no statistically significant difference was found (Student's t-test, P > 0.05). Conclusion. The range of processing times and endothelial cell counts in donor tissue available from the Eye Bank did not predict a change in the rate of graft dislocation in one surgeon's practice.