Measuring quality of care in autologous breast reconstruction: a Delphi consensus.

Measuring and benchmarking quality of care in surgical oncology has been gaining popularity. In autologous breast reconstruction (ABR), a standardized set of indicators to assess quality of care is lacking. In this study, we defined a set of evidence-based quality indicators for autologous breast reconstruction. First, we performed a systematic review to identify factors related to quality of care in ABR. Variables were categorized depending on their function: indicators related to outcome, indicators related to process and case-mix variables. The review was followed by a 3-round Delphi Consensus to determine which indicators and case-mix-variables were considered relevant and feasible for inclusion in an ABR standard set of indicators. 932 unique articles were identified, of which 110 papers were included in the study. Indicators were categorized by function: outcome, process and case-mix variables. In total, 8 process indicators and 41 outcome indicators were extracted. 30 case-mix-variables were included. Following 3 rounds of questioning in the Delphi Consensus, all respondents agreed on type of ABR, oncological outcomes and patient satisfaction for the standard set. Indicators related to complications were consistently ranked highly. Most process indicators were not chosen after 3 rounds of questioning. 11 case-mix-variables were included in the final set. Following the Delphi Consensus, it was possible to identify 33 process and outcome indicators and 11 case-mix-variables for inclusion for a standard set of quality indicators. With the inclusion of both objective and patient-reported outcome measures, this set of indicators provides a multidimensional measurement tool for quality assessment for ABR.

Targeted therapies and checkpoint inhibitors in sarcoma.

Sarcomas are defined as a group of mesenchymal malignancies with over 100 heterogeneous subtypes. As a rare and difficult to diagnose entity, micrometastasis is already present at the time of diagnosis in many cases. Current treatment practice of sarcomas consists mainly of surgery, (neo)adjuvant chemo- and/or radiotherapy. Although the past decade has shown that particular genetic abnormalities can promote the development of sarcomas, such as translocations, gain-of-function mutations, amplifications or tumor suppressor gene losses, these insights have not led to established alternative treatment strategies so far. Novel therapeutic concepts with immunotherapy at its forefront have experienced some remarkable success in different solid tumors while their impact in sarcoma remains limited. In this review, the most common immunotherapy strategies in sarcomas, such as immune checkpoint inhibitors, targeted therapy and cytokine therapy are concisely discussed. The programmed cell death (PD)-1/PD-1L axis and apoptosis-inducing cytokines, such as TNF-related apoptosis-inducing ligand (TRAIL), have not yielded the same success like in other solid tumors. However, in certain sarcoma subtypes, e.g. liposarcoma or undifferentiated pleomorphic sarcoma, encouraging results in some cases when employing immune checkpoint inhibitors in combination with other treatment options were found. Moreover, newer strategies such as the targeted therapy against the ancient cytokine macrophage migration inhibitory factor (MIF) may represent an interesting approach worth investigation in the future.

Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws.

We analyzed the results of 20 unstable metacarpal fractures in 15 patients treated with a cannulated compression screw and no immobilization. All fractures healed within 6 weeks. One patient with multiple fractures and a flexion deficit required arthrolysis of two metacarpophalangeal joints. Another patient had an extension lag. There were no other complications. This fast and easy technique results in good outcomes for unstable metacarpal fractures. The advantages are early active motion without immobilization and stable fixation. Surgical removal of the screw is rarely needed. LEVEL OF EVIDENCE: IV (therapeutic).

Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand: a review of 31 consecutive fractures.

UNLABELLED: We present the results of 26 patients with 31 consecutive displaced or unstable extra-articular fractures of the base and shaft of the proximal and middle phalanges of the digits of the hand, treated over a period of 12 months with an intramedullary headless compression screw and early mobilization with no splinting. All fractures healed with no major complications. Only one patient, who had a pathological fracture through an enchondroma, required a tenolysis to improve the mobility of the finger. This technique seems to be technically simple, effective and with few drawbacks. LEVEL OF EVIDENCE: IV.

Extending the limits of reconstructive microsurgery in elderly patients.

BACKGROUND: Population aging strongly affects the demographic development of industrialized countries. While microsurgical procedures were initially believed to be only feasible in patients of younger age because of the duration of the surgical procedure and the higher risk of vascular insufficiency due to age-related comorbidities, it has become evident that these procedures are beneficial even for patients at an advanced age. METHODS: We retrospectively investigated microsurgical procedures in a patient cohort (n = 25 with 27 free flaps) with a minimum age of 78 years with regard to patients' characteristics, flap survival, and postoperative surgical and medical complications. RESULTS: Median age was 81 years (IQR 6). Most defects were located in the head and neck region. The mean operation time was 384 min (standard deviation (SD) 131). Flap failure was observed in three cases (11%). The median length of hospital stay was 17 days (interquartile range (IQR) 8). The mean ASA score was 2.48. Patients' age and ASA group did not correlate. The mortality rate was 4%. Postoperative surgical complications were observed in 11 cases (41%), while 19 patients (70%) showed one or more medical complications. Higher ASA classes tended to show more postoperative complications. However, neither age nor operating time nor ASA status showed significant influence on the occurrence of postoperative medical or surgical complications. CONCLUSION: There is growing demand for structural and functional restoration using free tissue transfer in an aging population. If there are no alternative treatment options available promising similar structural and functional preservation, free tissue transfer is justifiably in very old patients despite a potentially increased flap failure. As such, free tissue transfer is used as a curative treatment concept aiming at a maximum of patients' independence and early ambulation. Occurrence of complications can be diminished by adequate patient selection and thorough perioperative care.

Sensitization and desensitization of burn patients as potential candidates for vascularized composite allotransplantation.

Sensitization describes the acquired ability of the immune system to react to foreign human leukocyte antigens (HLA) by producing antibodies and developing memory cells. In the field of transplantation, recipient preformed HLA antibodies due to previous sensitization have been identified - beneath ABO incompatibility - as a major factor for acute graft rejection. Several reasons for sensitization have largely been studied, such as previous blood transfusions, pregnancies or former transplants. Recent studies indicate that the use of assist devices (e.g. ECMO) or cadaveric skin allotransplantation providing temporary coverage in burn patients may lead to additional sensitization. As vascularized composite allotransplantation (VCA) has become a rapidly advancing therapeutic option for reconstruction of complex tissue defects in burns, it seems even more important to become familiar with immunological principles and to be cautiously aware of both sources of sensitization and therapeutic concepts in burns avoiding sensitization. This may also include emergency VCAs in burn patients as potential strategy for early definitive reconstruction avoiding procedures triggering HLA antibody formation. We hereby provide an overview on current evidence in the field of pre- and peritransplant sensitization, followed by posttransplant strategies of desensitization and their potential impact on future treatments of burn patients.

Long-term clinical outcome after epineural coaptation of digital nerves.

UNLABELLED: This study evaluates the long-term clinical outcome and complication rate after digital nerve repair in adults and aims to identify possible prognostic factors of sensory recovery. End-to-end epineural coaptation was performed under magnification. A total of 93 coapted digital nerves were clinically evaluated with a mean follow-up of 3.5 years (range 1-6 years). The mean two-point discrimination was 10.6 mm (versus 4.4 mm for the contralateral side). Cutaneous pressure threshold tested with Semmes-Weinstein monofilaments showed a mean value of 2.7 (versus 2.2 for the contralateral side). Only 2% of our patients developed painful neuromas. None of our patients recovered normal functional sensibility, however, recovery of protective sensation contributed to a high reported level of satisfaction. No correlation was observed between the sensory outcome and age, smoking, mechanism of injury, lesion to or anastomosis of a digital artery, or time of immobilization. The only identified predictor of the result was the surgeon's level of experience. This highlights the importance of adequate training and practice in the surgical repair of smaller peripheral nerves. LEVEL OF EVIDENCE: IV.

Major burn injuries associated with Christmas celebrations: a 41-year experience from Switzerland.

In Switzerland it is customary to light candles on Christmas trees and advent wreaths. This tradition leads to an increased risk of home fires. We reviewed the records of patients who sustained burn injuries from a lit Christmas tree or advent wreath during the Christmas holidays between January 1971 and January 2012. We treated 28 patients and observed 4 fatalities (mortality rate: 14%). 61% of the patients were male, 39% were female. The mean abbreviated burn severity index (ABSI) was 6.5 points in the group of the survivors and 10.8 points in the group of the non-survivors. The mean total body surface area burned (TBSA) for survivors was 18.9%, with 14.1% having full thickness burns; for the non-survivors the mean TBSA was 45.2%, with 38% having full thickness burns. The Mann-Whitney U-test showed a significant difference between the survivors and the fatalities concerning the mean total and full thickness burned body surface area (p value 0.009 and 0.012). More than sixty percent of the fires occurred in January and the most severe accidents were seen after January 4th. Despite Christmas decoration-associated fires being relatively uncommon, they tend to cause more serious injuries than regular household fires. We recommend that in countries where it is customary to set up flammable Christmas decorations, state-issued information pamphlets with instructions on fire safety conduct should be distributed.

En Suisse il est de coutume de mettre des bougies allumées sur les arbres de Noël et sur les couronnes de l'Avent. Cette tradition aument le risque d'incendies de maison. Nous avons examiné les dossiers de patients ayant subi des brûlures causées par un arbre de Noël ou une couronne de l'Avent pendant les vacances de Noël entre Janvier 1971 et Janvier 2012. Nous avons traité 28 patients et observé 4 décès (taux de mortalité: 14%). 61% des patients étaient des hommes, 39% étaient des femmes. La moyenne "indice abrégée de gravité de la brûlure" était de 6,5 points dans le groupe des survivants et 10,8 points dans le groupe des décédés. La moyenne de la surface corporelle totale brûlée (SCT) pour les survivants était de 18,9% - avec 14,1% ayant des brûlures au troisième degré; pour les non-survivants la moyenne SCT était de 45,2% - avec 38% ayant des brûlures au troisième degré. Le test U de Mann-Whitney a montré une différence significative entre les survivants et les non-survivants qui concerne la totale moyenne et l'épaisseur total brûlé de la surface du corps (valeur p de 0,009 et 0,012). Plus de 60% des incendies a eu lieu en Janvier et les accidents les plus graves ont été observés après le 4 Janvier. Meme si les incendies associés aux décorations de Noël sont relativement rares, ils ont tendance à causer des blessures plus graves que les incendies domestiques réguliers. Nous recommandons que, dans les pays où il est d'usage de mettre en place des décorations de Noël inflammables, les brochures d'information soient distribués par l'état avec des instructions sur le comportement de sécurité.

Replantation by palmar arteriovenous anastomosis in complex finger amputations.

Digital replantation is a well-established and increasingly common procedure in specialized hand surgery units worldwide. Replantation after complex trauma is often challenging due to severely injured, small-diameter vessels, especially at the distal level. Digit salvage by arteriovenous anastomosis has been inadequately described in the literature for such cases. The objective of this study was to evaluate the outcomes and complications of arteriovenous digital replantation in complex amputations. We reviewed five cases of digital replantation using a single palmar afferent arteriovenous anastomosis and drainage via a dorsal vein. The postoperative protocol followed our standard replantation protocol. All digits survived with no revision procedures. No major complications were observed. One digit developed partial epidermolysis and one thumb developed marginal skin necrosis, both treated conservatively. The color of the replanted digits was not a reliable monitoring parameter but capillary refill was consistently visible. Microangiography performed four months after surgery demonstrated good digit perfusion. Our results support palmar arteriovenous anastomosis as a reliable alternative in digital replantation if distal arteries are unavailable for anastomosis. The results also suggest that this digit salvage procedure can be carried out at a more proximal level than previously reported.

Carpal tunnel syndrome: Analysis of online patient information with the EQIP tool.

Patients suffering from carpal tunnel syndrome (CTS) actively search for medical information on the Internet. The World Wide Web represents the main source of patient information. The aim of this study was to systematically assess the quality of patient information about CTS in the Internet. A qualitative and quantitative assessment of websites was performed with the modified Ensuring Quality Information for Patients (EQIP) tool that contains 36 standardized items. Five hundred websites with information on CTS treatment options were identified through Google, Bing, Yahoo, Ask.com and AOL. Duplicates and irrelevant websites were excluded. One hundred and ten websites were included. Only five websites addressed more than 20 items; quality scores were not significantly different between the various providing groups. A median of 15 EQIP items was found, with the top website addressing 26 out of 36 items. Major complications such as median nerve injury were reported in 27% of the websites and their treatment in only 3%. This analysis revealed several critical shortcomings in the quality of the information provided to patients suffering from CTS. There is a collective need to provide interactive, informative and educational websites for standard procedures in hand surgery. These websites should be compatible with international quality standards for hand surgery procedures.

[Comparison of functional results with MRI findings after surgical treatment of transscaphoid perilunate fracture dislocations of the wrist: the role of scapholunate ligament lesions]. / Vergleich der funktionellen Resultate mit MRT-Befunden nach operativer Versorgung von transskaphoidalen perilunären Luxationsfrakturen: Die Rolle von skapholunären Bandläsionen.

PURPOSE: The aim of this study was to review the outcome of transscaphoid perilunate fracture dislocations by MRI to use the advantages of MRI to show the post-traumatic degenerative changes, the examination of cartilage, the integrity of the ligaments and the vascularisation of the carpal bones. A second aim of this study is to interpret the findings in correlation to the functional results and the individual perception of hand functionality (PRWE). PATIENTS AND METHODS: In this retrospective study, 20 patients (1 woman and 19 men), who were treated with open reduction and internal fixation at our institution, were reviewed at a mean of 67 (25-145) months postoperative. The mean age was 30 (12-73) years. The functional results were measured by range of motion (ROM), grip and pinch strength. The Mayo and Krimmer wrist scores were calculated and the SF-36 and the patient-rated wrist evaluation (PRWE) questionnaires were performed. Radiological findings included consolidation of the fracture and the radiological measures (revised carpal height, SL gap, SL and RL angle). An MRI, performed without a contrasting agent, was used to assess the degenerative changes of the joints, the vascularisation of the carpalia and the integrity of the SL ligament. Statistical data was calculated with SPSS. RESULTS: Range of motion and strength were reduced by 10-20% compared to the uninjured opposite side. Although the majority of the patients (85%) achieved good to very good results in the Mayo and Krimmer wrist scores, the MRI showed osteoarthritis in 95% of the cases in at least in 1 out of 5 patients evaluated intracarpal joints. MRI showed signs of complete SL ligament tears in 5 patients and a partial tear in 2 patients. The same group also showed the strongest degenerative changes. However, there was no correlation between patient satisfaction and imaging results. CONCLUSION: MRI findings, as well as X-ray findings, do not correlate with the subjective and objective functional outcomes after surgical treatment of transscaphoid perilunate fracture dislocations. It can be assumed that SL ligament lesions seen in MRI play a major role over the long term course.

[Osteoconductive behaviour of beta-tricalcium phosphate ceramics in osteoporotic, metaphyseal bone defects of the distal radius]. / Osteokonduktive Eigenschaften von Beta-Trikalzium-phosphat in osteoporotischen, metaphysären Radiusdefekten.

BACKGROUND: Surgical treatment of osteoporotic distal radius fractures with locking plates does not completely prevent loss of reduction. Additional bone deficit stabilisation with the use of bone substitute materials is receiving increased attention. Most knowledge on the in vivo behavior of bone substitutes originates from a small number of animal models after its implantation in young, good vascularized bone. PURPOSE: This paper investigates the osteoconductivity, resorption and biocompatibility of beta-tricalcium phosphate as a temporary bone replacement in osteoporotic type distal radius fractures. PATIENTS AND METHODS: 15 bone samples taken from the augmented area of the distal radius of elderly people during metal removal were examined. RESULTS: The material was found to be osteoconductive, good degradable, and biocompatible. Degrading process and remodelling to woven bone seem to require more time than in available comparative bioassays. CONCLUSIONS: The material is suitable for temporary replacement of lost, distal radius bone from the histological point of view.

Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap.

Fingertip injuries often result in fingernail defects. Reconstruction of this structure is important for adequate functional and aesthetic results. This study evaluates the eponychial flap reconstruction technique in 45 fingertip amputations with loss of more than half the fingernail. In 33 cases the procedure was performed in combination with a palmar island flap for pulp reconstruction. Average follow up was 5 months. All eponychial flaps healed uneventfully. In 44 cases, the pulp volume was restored without nail growth disturbance. Five complications (9%) were observed (pain, soft nail, and nail deformity). Only one hook nail deformity required reoperation. All patients were satisfied with the aesthetic and functional outcome. We found eponychial flap fingernail reconstruction effective even for injuries proximal to the lunula and have extended the indication for this technique to very proximal fingernail defects. Eponychial flap reconstruction is a simple, safe, and time-effective technique without donor site morbidity. Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip.

Hemi-hamate autograft arthroplasty for acute and chronic PIP joint fracture dislocations.

BACKGROUND: Treatment of fracture dislocations of the PIP joint represents a hand surgical challenge. In hemi-hamate arthroplasty, the palmar joint surface is reconstructed using an osteochondral graft from the hamate and the immediate stability permits early movement. MATERIAL AND METHODS: We performed hemi-hamate reconstructions in 10 patients (mean age 34.9 years), who sustained fractures of the base of the middle phalanx of ≥50% surface and dorsal PIP dislocations. Outcomes were assessed by clinical exam and X-ray. Evaluation criteria were range of motion of PIP and DIP joints, grip strength, joint alignment, complications and donor site morbidity. Mean follow-up was 8.6 months (range 3-14). Fractures mostly involved the 4th and 5th fingers, all patients were male. Indications were subluxation and comminuition in acute cases of <6 weeks (5 patients) and chronic pain and morning stiffness in chronic cases (5 patients). RESULTS: Operative treatment was performed in average after 93 days (range 0-371 days) after injury. Average PIP motion was 71° (range 0-90); DIP motion was 54° (range 10-90) with a mean PIP flexion contracture of 6.5° (range 0-20). Grip strength averaged 95% of the opposite hand. 4 patients had revision surgery (2× arthrolysis PIP joint, 2× screw shortening, 1× neurolysis R. dorsalis N. ulnaris). CONCLUSIONS: Hemi-hamate autograft arthroplasty represents an effective procedure to address severe PIP joint fracture dislocations. It restores the comminuted articular surface in chronic injuries and in the acute injury it is a challenging but valuable alternative to extension block splinting. However, donor site morbidity and revision surgery have to be taken into account.

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis: long-term follow-up.

Radioscapholunate arthrodesis is the treatment of choice for symptomatic, degenerative radioscapholunate osteoarthritis. We report on three patients after radioscapholunate arthrodesis with a follow-up of 22-28 years. There were no short-term postoperative complications; range of motion and strength were stable. All three patients showed radiological evidence of progressive, but clinically asymptomatic midcarpal osteoarthritis. The conversion rate for radioscapholunate to panarthrodesis of the wrist is reported at 31% with follow-ups of more than five years, invariably due to either non-union, or progressive, symptomatic midcarpal osteoarthritis. Primary excision of the distal pole of the scaphoid during radioscapholunate arthrodesis probably plays an important role in avoiding these conditions in the long-term. This measure allows a residual range of motion more than previously believed; considering that the dart thrower's motion is the physiological axis of wrist motion.

Morphology and hemodynamics during vascular regeneration in critically ischemic murine skin studied by intravital microscopy techniques.

BACKGROUND: With the understanding of angiogenesis and arteriogenesis, new theories about the orchestration of these processes have emerged. The aim of this study was to develop an in vivo model that enables visualization of vascular regenerating mechanisms by intravital microscopy techniques in collateral arteriolar flap vascularity. METHODS: A dorsal skin flap (15 × 30 mm) was created in mice and fixed into a skinfold chamber to allow for assessment of morphology and microhemodynamics by intravital fluorescence microscopy (IVFM). Laser scanning confocal microscopy (LSCM) was utilized for three-dimensional reconstruction of the microvascular architecture. RESULTS: Flap tpO(2) was 5.3 ± 0.9 versus 30.5 ± 1.2 mm Hg in controls (p < 0.01). The collateral arterioles in the flap tissue were dilated (29.4 ± 5.3 µm; p < 0.01 vs. controls) and lengthened in a tortuous manner (tortuosity index 1.00 on day 1 vs. 1.35± 0.05 on day 12; p < 0.01). Functional capillary density was increased from 121.00 ± 25 to 170 ± 30 cm/cm(2) (day 12; p < 0.01) as a result of angiogenesis. Morphological evidence of angiogenesis on capillary level and vascular remodeling on arteriolar level could be demonstrated by IVFM and LSCM. CONCLUSIONS: Present intravital microscopy techniques offer unique opportunities to study structural changes and hemodynamic effects of vascular regeneration in this extended axial pattern flap model.

[The role of surgery in the treatment of cutaneous melanoma]. / Die Rolle der Chirurgie in der Behandlung des kutanen Melanoms.

Historically, melanoma patients were subject to wide local excisions and elective lymph node dissections. Both approaches were the focus of intense scrutiny in the past three decades, and many surgical dogmas were abolished. The role of surgery in providing local control over the primary tumor is largely undisputed. In addition, the surgical management strategies of the regional lymph nodes have undergone considerable change in the past; with lymphatic mapping and sentinel lymph node identification being the most relevant contribution, allowing selection of patients for adjuvant treatment (completion lymph node dissection, Interferon therapy). Surgery has also a place in palliative treatment of isolated systemic metastases for selected cases with good performance status in Stage IV melanoma.

[Reconstruction of isolated axillary nerve lesions: clinical and electrophysiological long-term results]. / Rekonstruktion isolierter Läsionen des N. axillaris: klinische und elektrophysiologische Langzeitresultate.

PURPOSE: The purpose of this retrospective study was the clinical and electrophysiological assessment of long-term results following surgical treatment of isolated axillary nerve lesions. PATIENTS AND METHOD: 10 patients, who underwent axillary nerve reconstruction using a nerve graft (80%) or a neurolysis alone (20%), with a follow-up period of 6.7 years (1.6-10.8 years) on average, were included in the study. In addition to the clinical examination, we examined reinnervation by electrophysiological methods and analysed their correlation to clinical results. RESULTS: 30% of the patients had muscle strength of M5 and full active range of motion of 180°, 40% reached M4 and averaged 170° (80-180°), 30% of the patients M3 and 65° (40-90°). In patients with M5, muscle compound action potential averaged 40% of the contralateral side (21-62%), in patients with M4 36% (29-58%), and in patients with M3 7% (3-11%). Good results were associated with younger patient age, a short delay prior to the operation and neurolysis alone (indicated by intraoperative electroneurography). CONCLUSION: The good results confirm our treatment algorithm for isolated axillary nerve lesions by neurolysis alone or reconstruction with autologous nerve transplantation. Measurement of compound muscle action potential is a valuable addition to difficult clinical assessment, as its amplitude enables quantification of axillary nerve recovery.

Diagnostic pitfall: pigmented lesion of the nipple--correlation between dermoscopy, reflectance confocal microscopy and histopathology.

We present an unusual case of a nevus of the nipple changing during pregnancy which caused a diagnostic pitfall. Nevi on the nipple and areola are infrequent, and diagnostic criteria for clinical, dermoscopy or reflectance confocal microscopy examination for nevi in this 'special location' are still missing. We comment on the literature on dermoscopic findings in mammary lesions and their management during pregnancy, as well as the challenging histopathology of nevi along the milk line. Finally, we focus on two main limitations of reflectance confocal microscopy: the misinterpretation of dendritic cells and the limitation of the imaging depth.